Other·May 3, 2017

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 recertification survey conducted from 4/17/17 though 4/21/17. The facility was licensed for 130 beds. The census at the time of the survey was 116 plus one bed-hold. The sample size was 24. For Entity Reported Incident CA00531348 regarding Quality of Care/Treatment, the Department did not substantiate a violation of federal or state regulations. For Entity Reported Incident CA00531875 regarding Quality of Care/Treatment, a federal deficiency was identified (see F226). A Class "B" Citation was also issued under F226. For Entity Reported Incident CA00531880 regarding Quality of Care/Treatment, federal deficiencies were identified (see F165 and

F226). A Class "B" Citation was also issued under F226. Representing the California Department of Public Health: 29259, Health Facilities Evaluator Nurse; 35157, Health Facilities Evaluator Nurse; 36044, Health Facilities Evaluator Nurse; 37409, Health Facilities Evaluator Nurse; and 38573, Health Facilities Evaluator Nurse.

F165 SS=D RIGHT TO VOICE GRIEVANCES WITHOUT REPRISAL CFR(s): 483.10(j)(1)

F165 05/12/2017 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: IRIO11 Facility ID: CA070000086 If continuation sheet 1 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 (j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one nonsampled resident (Resident 32) could voice a grievance with regard to the care and treatment provided without fear of reprisal. This failure impinged on the resident's right to be treated with dignity and respect. Findings: During an interview on 4/20/17, at 3:15 p.m., Resident 32 stated she was in the dining room sitting at a table during the evening meal about two months prior. She stated another resident was sitting at the table adjacent to her with her dinner tray. She stated a certified nurse assistant (CNA) was sitting next to her drinking coffee and not helping the resident eat. Resident 32 stated she asked the CNA if she was going to feed the other resident. The following day, Resident 32 stated she reported the CNA's failure to timely feed the resident to the director of staff development (DSD). Later the same day, Resident 32 stated the CNA came into the dining room and yelled at her for reporting her to the DSD. Since the incident, Resident 32 stated the CNA and her friends do not serve her tray during meals. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 2 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 Review of the facility's 11/2010 policy, "Filing Grievances/Complaints", indicated any resident may file a grievance or a complaint concerning treatment without fear of threat or reprisal in any form.

F174 SS=D RIGHT TO TELEPHONE ACCESS WITH PRIVACY CFR(s): 483.10(g)(6)(7)(i)

F174 05/19/2017 (g)(6) The resident has the right to have reasonable access to the use of a telephone, including TTY and TDD services, and a place in the facility where calls can be made without being overheard. This includes the right to retain and use a cellular phone at the resident's own expense. (g)(7) The facility must protect and facilitate that resident's right to communicate with individuals and entities within and external to the facility, including reasonable access to: (i) A telephone, including TTY and TDD services; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide two nonsampled residents (Residents 28 and 31) with access to a telephone in a place where calls can be made without being overheard. This failure impinged on the residents' rights to privacy. Findings: 1. During an observation and interview on 4/18/17, at 9:30 a.m., Resident 28 was observed making a telephone call to a family member at the nurses' station at Station 3. During a concurrent interview, Resident 28 stated she was unable to have a private FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 3 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 conversation with her family member because her telephone call could be overheard by anyone in the vicinity of Station 3. During an interview on 4/20/17, at 11 a.m., the director of staff development (DSD), stated the facility has two cordless telephones the residents can use which are located at Station 1. She stated there are no other cordless telephones located at Stations 2 and 3. She also stated the residents can use the telephones located at the nursing stations which are not cordless. 2. During an observation and interview on 4/20/17, at 2:20 p.m., Resident 31 was observed making a telephone call to arrange transportation at the nurses' station at Station 2. She stated the facility has cordless telephones for the residents to use but the telephones are either being used or not charged. As a result, she had to use the telephone at the nurses' station and other people can overhear her conversation. A review of the facility's 10/2010 policy, "Resident Rights", indicated the residents had the right to use a telephone in private and the facility shall provide a cordless telephone upon the resident's request.

F226 SS=D DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 05/12/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 4 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement their policy and procedure for one of 24 sampled residents (Resident 19) and one nonsampled resident (Resident 32) when allegations of abuse were not investigated and reported to the ombudsman and the California Department of Public Health (CDPH) within 24 hours as required. Failure to investigate the abuse in a timely manner potentially allowed the abuse to continue, allowed the alleged abusers to have access to the residents, and failed to protect the residents from harm. Findings: 1. During an interview with Resident 19 during FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 5 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 a quality of life assessment on 4/19/17, at 11:20 a.m., she stated during the second day of her readmission on 4/12/17, certified nurse assistant J (CNA J) made a comment and told her, "Look at you, your fat face, you're putting weight on yourself." Resident 19 reported the CNA's abusive language to social worker G (SW G) and asked SW G to keep her name confidential to prevent retaliation from CNA J. During a phone interview with SW G on 4/20/17, at 11:16 a.m., she stated she received the report from Resident 19 and considered it verbal abuse so she reported it to the director of staff development (DSD) on 4/14/17. During a follow-up interview with the DSD on 4/20/17, at 2:20 p.m., she stated she received written notes from SW G on 4/14/17 and she did not investigate the alleged incident because the director of nurses (DON) was also informed of the alleged verbal abuse. During an interview with the DON on 4/20/17, at 4:20 p.m., she stated she was not aware of this verbal abuse and if she knew about it she would have investigated and reported it. 2. During an interview on 4/20/17, at 3:15 p.m., Resident 32 stated she was in the dining room sitting at a table during the evening meal about two months prior. She stated another resident was sitting at the table adjacent to her with her dinner tray. She stated a CNA was sitting next to her drinking coffee and not helping the resident eat. Resident 32 stated she asked the CNA if she was going to feed the other resident. The following day, Resident 32 stated she reported the CNA's failure to timely feed the resident to the DSD. Later the same day, Resident 32 stated the CNA came into the dining room and yelled at her for reporting her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 6 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 to the DSD. Since the incident, Resident 32 stated the CNA and her friends do not serve her tray during meals. During an interview on 4/20/17, at 3:30 p.m., with the DSD, she stated the CNA denied yelling at Resident 32. The DSD stated she did not report the alleged incident of verbal abuse to the DON or anyone else. Review of the facility's 6/24/16 policy, "Policy and Procedure on Abuse Prevention and Reporting", indicated abuse, including verbal abuse, must be reported as soon as possible, but not to exceed 24 hours after the discovery of the incident, to the administrator of the facility, the ombudsman or local law enforcement, and the Department of Public Health Licensing Agency.

F248 SS=D ACTIVITIES MEET INTERESTS/NEEDS OF EACH RES CFR(s): 483.24(c)(1)

F248 05/19/2017 (c) Activities. (1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide an activity program to reflect the residents' needs and choices when the movies shown were too old. This failure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 7 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 could affect the residents' mental and psychosocial well-being. Findings: During the group interview on 4/18/17, at 2 p.m., six of nine residents (Residents 25, 26, 29, 30, 31, and 32) complained about the movies shown during the movie activity on Sunday afternoons. Residents 25, 26, 29, 30, and 32 stated the movies are too old and the activity staff does not ask them what movies they would like to watch. Resident 26 stated he does not attend the movie presentations any more because they are so old. Residents 29 and 30 stated they would like to watch some current movies. Resident 30 stated her family members bought her a DVD player (an electronic device that plays discs produced under DVD-video and DVD-audio technical standards which is connected to a television to watch the DVD content which could be a movie or a recorded television show) so she can watch current movies. Resident 31 stated the quality of the sound was poor so she purchased her own DVD player and does not attend the movie presentations anymore. Resident 32 stated the group has complained to the activity director (AD) about the age of the movies for over a year. During an interview on 4/20/17, at 8:45 a.m. with the AD, she stated she was aware of the complaints made by some of the residents regarding old movies. She stated it was difficult to accommodate the residents' preferences for movies as some residents prefer old movies. A review of the facility's 12/2006 policy, "Activities and Social Services", indicated residents shall have the right to choose the types of activities in which they wish to participate and the facility will provide activities FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 8 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 compatible with the residents' interests.

F252 SS=D SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT CFR(s): 483.10(e)(2)(i)(1)(i)(ii)

F252 05/19/2017 (e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. §483.10(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a clean and homelike environment for the residents when the fans in three resident rooms and the vent in one shower room were covered with gray particulate matter. These failures had the potential to affect the residents' physical and emotional well-being. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 9 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 the environmental tour on 4/18/17, at 10:30 a.m., and accompanied by the maintenance supervisor, (MS), the assistant maintenance supervisor (AMS), and the housekeeping supervisor (HS), the electrical fans in Rooms 116, 202, and 205, and the vent in the shower room in Station 2 were covered with gray particulate matter. During a concurrent interview with the MS, he stated cleaning the fans and the vents was part of routine maintenance. He also stated there was no routine maintenance schedule. A review of the facility's 12/ 2009 policy, "Maintenance Service", indicated the maintenance department is responsible for maintaining all equipment in good working order and is to provide routine scheduled maintenance service to all areas.

F281 SS=D SERVICES PROVIDED MEET PROFESSIONAL STANDARDS CFR(s): 483.21(b)(3)(i)

F281 05/19/2017 (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to meet professional standards of care for three of 24 sampled residents (Residents 2, 3, and 21) when a skin tear on Resident 2's left middle finger was not assessed and treatment was not provided in a timely manner, when the fall care plan FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 10 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 interventions for Resident 3 were not followed, and when Resident 21's pacemaker was not assessed and a complete care plan was not developed. These failures had the potential to place the residents at risk for health complications. Findings: 1. Resident 2's clinical record was reviewed and indicated he was admitted to the facility with diagnoses including Parkinson's disease (disorder of the central nervous system affecting movement and often causing tremors), mild cognitive impairment, hypertension (high blood pressure), muscle weakness, and difficulty walking. He was admitted to hospice care (provision of care for the sick, especially the terminally ill) on 1/24/17. A physician order and the Treatment Administration Record (TAR), dated 4/2017, indicated there was no treatment order for a skin tear. During an observation on 4/17/17, at 11 a.m., Resident 2 was sitting in a wheelchair in his room. His left middle finger had a 0.5 centimeter (cm, unit of measurement) x 0.5 cm skin tear with dried blood. During an observation on 4/18/17, at 10:30 a.m., Resident 2 was lying in bed. The skin tear on his left middle finger was not covered. During an interview with certified nurse assistant F (CNA F), on 4/19/17, at 12:25 p.m., she stated she reported Resident 2's skin tear on his left middle finger to licensed vocational nurse D (LVN D) on 4/17/17, at breakfast time. During an interview with LVN D, on 4/19/17, at 12:30 p.m., she stated CNA F reported Resident 2's skin tear to her on 4/17/17. She stated hospice registered nurse E (HRN E) was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 11 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 in the facility on 4/17/17, she reported the resident's skin tear to him, and he stated he would take care of it. During a telephone interview with HRN E, on 4/20/17, at 2:35 p.m., he stated he came to the facility on 4/17/17 to assess Resident 2's condition. He stated he did not notice any skin problem and LVN D did not tell him about any skin problem. The facility's undated policy, "Skin and Wound Management", indicated "All Nursing Staff is responsible for the prompt reporting of any skin related conditions to the Licensed Nurse. The Licensed Nurse will notify the Attending Physician promptly at the first occurrence of a pressure ulcer or other skin related problems." 2. A review of Resident 3's Care Conferences over the last three quarters (1/20/16, 8/11/16, and 4/13/17) indicated the resident had numerous falls without injuries. Resident 3 was a high fall risk due to his diagnoses of dementia (a group of symptoms affecting mental cognitive tasks such as reasoning and memory), falls, and behavior problems. His fall prevention care plan included interventions of a bed alarm and a lap buddy (an inflatable pillow fitting into the frame of the wheelchair to remind the resident to ask for help before getting up). A physician telephone order, dated 4/19/17, at 9 a.m., indicated an order to "Apply bed alarm as a monitoring device. Check placement and functioning". During an observation of Resident 3 in his room on 4/19/17, he was up in his wheelchair with a lap buddy in place. The bed alarm was off. During an interview with CNA L, on 4/19/17, at 10:05 a.m., she stated she turned off the bed alarm when she checked on Resident 3 earlier, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 12 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 but forgot to turn it back on. The bed alarm was tested three times and it did not work. CNA L confirmed the alarm was not working. She also stated the resident can transfer from his wheelchair to his bed without assistance. During an interview with the assistant director of nurses (ADON) on 4/20/17, at 11:40 a.m., she stated the CNA should ensure the bed alarm was on and was functional. A review of the facility's policy, revised on 5/22/12, "Fall Prevention and Management", under High Risk Prevention, indicated "Use of personal alarms as monitoring device while in bed or wheelchair if applicable or appropriate for resident, will be implemented." 3. Resident 21's clinical record was reviewed and indicated she was admitted to the facility in 3/2017 and again in 4/2017. Her diagnoses included a pacemaker (a device implanted into the chest to control abnormal heart rhythms). Her care plan, dated 4/5/17, indicated the pacemaker was to be "monitored according to schedule" and she was to stay away from microwaves and electric razors. There was no documentation in the care plan or her chart indicating when and how the pacemaker was to be "monitored according to schedule." There was no documentation regarding the pacemaker's manufacturer or model, the settings, the heart range, the date of insertion, and the frequency of checks. In addition, there was no documentation indicating when the resident's apical and radial pulses should be taken and no indication the resident should have been monitored for chest pain, shortness of breath, dizziness, low blood pressure, an irregular heart rhythm, and changes from the pacemaker's set rate. There also was no indication the resident was monitored at all for pacemaker malfunction. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 13 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 During an interview on 4/20/17, at 9:30 a.m., with LVN I, she reviewed Resident 21's clinical record and stated she was unable to find any specific information regarding the resident's pacemaker. She also stated she was unable to find a comprehensive care plan regarding the resident's pacemaker or any indication of specific monitoring. During an interview on 4/20/17, at 9:45 a.m., with the Minimum Data Set (MDS, an assessment tool) coordinator (MDSC), she reviewed Resident 21's clinical record and stated she was unable to find any specific information regarding the resident's pacemaker. She also stated she was unable to find a comprehensive care plan regarding the resident's pacemaker or any indication of specific monitoring. During an interview on 4/20/17, at 10:10 a.m., with LVN K, she stated she provided care for Resident 21 during her two admissions. She stated she was not aware Resident 21 had a pacemaker. During an interview on 4/20/17, at 2 p.m., with the director of nurses (DON), she reviewed Resident 21's clinical record and stated she was unable to find any specific information regarding the resident's pacemaker. She also stated she was unable to find a comprehensive care plan regarding the resident's pacemaker or any indication of specific monitoring. The DON stated the pacemaker care plan should include the name of the manufacturer and serial number of the pacemaker, the settings, the heart range, the monitoring schedule, and the specific indications the nurses should be monitoring to detect a possible malfunction. Review of the facility's undated policy, "Care of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 14 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 a Resident with a Pacemaker", indicated the pacemaker battery should be monitored and the resident should be monitored for changes in the heart's electrical activity, fainting, shortness of breath, dizziness, fatigue, and confusion.

F332 SS=D FREE OF MEDICATION ERROR RATES OF 5% OR MORE CFR(s): 483.45(f)(1)

F332 05/19/2017 (f) Medication Errors. The facility must ensure that its(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility had a 12.1% medication error rate when four medication errors in 33 opportunities were observed during the medication pass for one of 24 sampled residents (Resident 16) and two nonsampled residents (Residents 35 and 36). These failures had the potential to negatively affect the residents' health and well-being. Findings: 1. During a medication pass observation on 4/17/17, at 5:10 p.m., licensed vocational nurse A (LVN A) administered four medications to Resident 16 including three insulins (a soluble medication used to lower blood sugar level): Novolin-R regular (a short-acting insulin), Humalog U-100 lispro (a rapid-acting insulin), and Humulin-N NPH (an intermediate-acting insulin). LVN A drew eight units of regular insulin into an insulin syringe, then four units of lispro insulin into the same syringe, and 47 units of NPH insulin into the same syringe. She then administered all 59 units of insulin to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 15 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 Resident 16 via a subcutaneous injection (applied under the skin). During an interview with LVN A, on 4/17/17, at 5:45 p.m., she stated she thought she could draw regular insulin, lispro insulin, and NPH insulin into the same syringe. During an interview with the director of nurses (DON), on 4/18/17, at 11:50 a.m., she stated she thought Lantus (a long-acting insulin) was the only insulin that could not be mixed with the other insulins. The Package Insert (Drug Information) for Humalog U-100 subcutaneous injection route, indicated "Humalog U-100 may be mixed with NPH insulin preparations only." During an interview with the DON, on 4/19/17, at 12:05 p.m., she reviewed the Package Insert for Humalog U-100 and acknowledged Humalog U-100 may be mixed with NPH insulin preparations only when administered via a subcutaneous injection route. 2. During a medication pass observation on 4/18/17, at 8:25 a.m., LVN B administered one puff of Qvar (a drug used to prevent and control wheezing and shortness of breath) oral inhalation 80 micrograms (mcg, unit of measurement) to Resident 35 and did not instruct her to exhale prior to the administration and hold her breath after the administration. Resident 35 opened her mouth and rinsed it right after the administration of the Qvar. During an interview with LVN B, on 4/18/17, at 8:45 a.m., she acknowledged she did not instruct Resident 35 to exhale prior to the administration and to hold her breath after the administration of Qvar. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 16 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 3. The clinical record for Resident 36 was reviewed. The physician order, dated 4/25/16, indicated the resident was to receive metoprolol tartrate 50 mg 1 tablet by mouth twice a day for hypertension. The Medication Administration Record (MAR), dated 4/2017, indicated metoprolol tartrate 50 mg was to be administered at 9 a.m. and 5 p.m. every day. During a medication pass observation on 4/18/17, at 8:55 a.m., LVN C administered one puff of Advair (a drug used to prevent and control wheezing and shortness of breath) oral inhalation 230-21 mcg to Resident 36 and did not instruct her to exhale prior to the administration and to hold her breath after the administration. Resident 36 opened her mouth and rinsed it right after the administration of the Advair. During a concurrent observation, LVN C did not administer metoprolol tartrate (a medication used to treat chest pain, heart failure and high blood pressure) 50 milligrams (mg, unit of measurement) to Resident 36. During an interview with LVN C, on 4/18/17, at 9:10 a.m., she acknowledged she did not instruct Resident 36 to exhale prior to the administration and to hold her breath after the administration of Advair. During an interview with LVN C, on 4/18/17, at 11:25 a.m., she acknowledged she did not administer metoprolol tartrate 50 mg to Resident 36 and she would call and ask the physician if she could administer it to the Resident at 11:30 a.m. The facility's 2007 policy, "Medication Administration-Oral Inhalations", indicated "Ask resident to breathe out ... Place inhaler mouthpiece under top teeth and above tongue FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 17 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 mouth/lips closed around the mouthpiece ... Press down on inhaler once to release medications ... Hold breath for 5-10 seconds ..." The facility's 2007 policy, "Medication Administration-General Guidelines (California Specific)", indicated "Medications are administered in accordance with written orders of the prescriber."

F333 SS=D RESIDENTS FREE OF SIGNIFICANT MED ERRORS CFR(s): 483.45(f)(2)

F333 05/19/2017 483.45(f) Medication Errors. The facility must ensure that its(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 16) was free from a significant medication error when licensed vocational nurse A (LVN A) administered two insulins (a soluble medication used to lower blood sugar level), Humalog U-100 lispro (a rapid-acting insulin) and Novolin-R regular (a short-acting insulin), mixed together in the same syringe to the resident. This failure had the potential to adversely affect the resident. Findings: During a medication pass observation on 4/17/17, at 5:10 p.m., LVN A administered four medications to Resident 16 including three insulins: Novolin-R regular, Humalog U-100 lispro, and Humulin-N NPH (an intermediateacting insulin). LVN A drew eight units of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 18 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 regular insulin into an insulin syringe, then four units of lispro insulin into the same syringe, and 47 units of NPH insulin into the same syringe. She administered all 59 units of insulin to Resident 16 via a subcutaneous injection (applied under the skin). During an interview with LVN A, on 4/17/17, at 5:45 p.m., she stated she thought she could draw regular insulin, lispro insulin, and NPH insulin into the same syringe. During an interview with the director of nurses (DON), on 4/18/17, at 11:50 a.m., she stated she thought Lantus (a long-acting insulin) was the only insulin that could not be mixed with other insulins. The Package Insert (Drug Information) for Humalog U-100 subcutaneous injection route, indicated "Humalog U-100 may be mixed with NPH insulin preparations only." During an interview with the DON, on 4/19/17, at 12:05 p.m., she reviewed the Package Insert for Humalog U-100 and acknowledged Humalog U-100 may be mixed with NPH insulin preparations only when administering via a subcutaneous injection route.

F365 SS=D FOOD IN FORM TO MEET INDIVIDUAL NEEDS CFR(s): 483.60(d)(3)

F365 05/19/2017 (3) Food prepared in a form designed to meet individual needs; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow their policy and procedure to check the accuracy of food trays for four of 24 sampled residents (Residents 1, 3, 4, and 9) and one nonsampled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 19 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 resident (Resident 33) during breakfast and lunch. These failures had the potential not to meet each residents' individual needs. Findings: A review of the food history/preference list, dated 2/21/17, for Resident 1 indicated juice and tea should be served for breakfast, and soy milk should be served for lunch and dinner. A meal observation and a review of the diet card for Resident 1 on 4/17/17, at 12 p.m., indicated Resident 1 should receive juice for lunch. Soy milk, not juice, was observed on her lunch tray. During an interview with licensed vocational nurse I (LVN I) on 4/17/17, at 12:25 p.m., she stated according to Resident 1's diet card, she should receive juice and not soy milk during the lunch meal and the certified nurse assistant (CNA) should check the diet card before serving Resident 1 to make sure the food trays were accurate. Meal observations and a review of the diet cards for Residents 3, 4, 9, and 33 on 4/18/17, at 7:30 a.m., indicated Resident 3 should have two cups of coffee for breakfast but he only had one, Resident 4 should have one cup of coffee for breakfast but she had none, Resident 9 should not have coffee during meals but she had a cup on her breakfast tray, and Resident 33 should receive a cup of coffee for breakfast but she had none. During an interview with the dietary service supervisor (DSS) on 4/18/17, at 8 a.m., she stated the kitchen staff was to prepare the trays according to the diet cards and then, the licensed nurses and the CNAs should check the accuracy of the diet cards and the food trays during tray delivery. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 20 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 During an interview with the director of staff development (DSD) on 4/19/17, at 7:50 a.m., she stated the accuracy of the diet cards should be checked by the licensed nurse during the weekly summary and the accuracy of the food trays should be checked by the CNAs before serving or delivering the food trays to the residents. The facility's 2012 policy, "Nutritional Care Management/Verification of Diet Orders", indicated the facility should implement procedures for verification of the accuracy of the diet orders and the accuracy of the diets served to the residents. The tray should also be checked by the employees serving the trays before giving the tray to the resident. The dietary staff should refer to the tray card for dislikes and substitute appropriately for those items. Before the delivery of a resident's tray, the CNAs should check each tray for problems with tray accuracy and any inaccuracies should be resolved immediately.

F371 SS=E FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 05/19/2017 (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 21 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions when several food items were outdated in the dry storage and kitchen areas. These failures had the potential to cause food-borne illness. Findings: During the initial kitchen tour with the dietary service supervisor (DSS) on 4/17/17, at 7:30 a.m., there were two bags of six inch french rolls with an expiration date of 4/14/17, a bag of tortillas with an opened date of 2/9/17 and an expiration date of 3/8/17, three bags of raisin bran cereal with open dates of 8/10/16, and a leftover tray with four bowls of raisin bran cereal dated 4/10/17 in the dry food storage. During a concurrent interview with the DSS, she confirmed the presence of the expired items and stated the expired food items should not be served to the residents and should be thrown away. During an observation in the kitchen food preparation area on 4/17/17, at 8:10 a.m., there were five bananas with black dots sitting on the food trays. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 22 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 During a concurrent interview with dietary aide H (DA H), he stated the bananas were for the residents. During a follow-up interview with the DSS on 4/17/17, at 8:20 a.m., she stated the bananas should be thrown away and should not have been served to the residents. The facility's 2012 policy, "Food Service Management/Storage of Food and Non-Food Supplies", indicated all open food items will have an open date and a use-by-date per the manufacture's guidelines. Food should be stocked using the first-in, first-out policy. Bread should be stored on racks with good air circulation and it was best to use the product within three days. Bananas should be stored at room temperature and used as quickly as possible after ripening.

F431 SS=D DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 05/19/2017 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 23 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure medications were properly stored when two bottles of expired medication were observed in the Station 3 medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 24 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 room. These failures had the potential to place residents at risk for receiving expired medications which could affect their effectiveness. Findings: During an observation on 4/17/17, at 11:45 a.m., in the Station 3 medication room, two bottles of oyster shell calcium (a medication used to prevent or treat low blood calcium level) 500 milligrams (mg, a unit of measurement) were found with an expiration date of 3/2017. During a concurrent interview, the assistant director of nursing (ADON) confirmed the above findings. The facility's 2007 policy, "Medication StorageStorage of Medication (California Specific)", indicated "Outdated, contaminated, discontinued or deteriorated medications ... are immediately removed from stock, disposed of according to procedures for medication disposal ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 25 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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

F458 BEDROOMS MEASURE AT LEAST 80 SQ FT/RESIDENT CFR(s): 483.90(e)(1)(ii)

F458 05/19/2017

F514 05/19/2017 SS=B PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure Room 119 had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive in the facility. Findings: Measurement of Room 119 indicated the room had less than 80 square feet per resident. Room 119 was a two-bed room, which measured 71.25 square feet per resident. Room 119 did not inhibit the staff from providing adequate care for the residents. The staff and the residents moved freely in the room. Wheelchairs were easily accommodated. The residents and the staff stated the square footage of the room was not a concern. Continuance of the room waiver is recommended.

F514 SS=D RES RECORDSCOMPLETE/ACCURATE/ACCESSIBLE CFR(s): 483.70(i)(1)(5) (i) Medical records. (1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 26 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized (5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident’s assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician’s, nurse’s, and other licensed professional’s progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain an accurate clinical record for one nonsampled resident (Resident 36) and to ensure controlled medications for two nonsampled residents (Residents 37 and 38) were fully accounted for when: 1. Licensed vocational nurse C (LVN C) did not administer metoprolol tartrate (a medication used to treat chest pain, heart failure and high FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 27 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 blood pressure) 50 milligrams (mg, unit of measurement) to Resident 36 but documented she did on the Medication Administration Record (MAR), and 2. Controlled medications were signed out of the Controlled Drug Record (CDR, an inventory sheet) but not documented on the MAR. These failures potentially resulted in inaccurate data necessary to assess, treat the residents, and meet the residents' needs and in inaccurate accountability for controlled medications. Findings: 1. The clinical record for Resident 36 was reviewed on 4/18/17. The physician order, dated 4/25/16, indicated the resident was to receive metoprolol tartrate 50 mg 1 tablet by mouth twice a day for hypertension. The MAR, dated 4/2017, indicated metoprolol tartrate 50 mg was to be administered at 9 a.m. and 5 p.m. every day. During a medication pass observation on 4/18/17, at 8:55 a.m., LVN C did not administer metoprolol tartrate 50 mg to Resident 36. During an interview with LVN C, on 4/18/17, at 11:25 a.m., she acknowledged she did not administer metoprolol tartrate 50 mg to Resident 36, but she signed the MAR documenting she administered the medication to Resident 36 at 9 a.m. 2. Review of the CDR for Resident 37's Norco (a pain reliever) 5-325 mg indicated the medication was signed out on 1/26/17, at 8:30 a.m., on 2/14/17, at 8:10 a.m., and on 2/21/17, at 7 p.m., twice, but there was no documentation of these administrations on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 28 of 29 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: _______________ 055884 (X3) DATE SURVEY COMPLETED 04/21/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CREEKSIDE POST-ACUTE 3580 Payne Ave 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 Resident 37's MAR. Review of the CDR for Resident 38's oxycodone (a pain reliever) 5 mg indicated the medication was signed out on 3/5/17, at 1:15 a.m., on 3/26/17, at 8 p.m., and on 3/28/17, at 3 a.m., but there was no documentation of these administrations on Resident 38's MAR. During an interview with the director of nurses (DON), on 4/19/17, at 4 p.m., she reviewed the records of Residents 37 and 38 and confirmed the above findings. The facility's 2007 policy,"Medication Administration-General Guidelines (California Specific)", indicated, "The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given" and "The licensed nurse administers the controlled medication and documents dose administration on the MAR." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IRIO11 Facility ID: CA070000086 If continuation sheet 29 of 29