Other·August 10, 2017

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 conducted on 7/27/17, 7/31/17, 8/1/17, 8/4/17, and 8/7/17. For Entity Reported Incident CA00545367 and Complaint CA00546115 regarding Quality of Care/Treatment (Resident Safety/Falls) a federal deficiency was identified (see F323). In addition, a Class "B" Federal Citation was issued. Inspection was limited to the specific entity reported incident and complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health, 34432, Health Facilities Evaluator Nurse.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 09/01/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to 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: PX9011 Facility ID: CA070000086 If continuation sheet 1 of 5 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 08/07/2017 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 use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide a safe environment for one of three sampled residents (Resident 1) when Resident 1 was placed on her left side near the edge of her bed and fell from the bed head first as certified nursing assistant A (CNA A) was pulling on Resident 1's clothing. This failure resulted in Resident 1 sustaining a cervical (neck) fracture, a right facial fracture and a laceration of her right eyebrow. Findings: Review of Resident 1's record was initiated on 7/27/17. Resident 1 had diagnoses of atrial fibrillation (irregular heart beat), on warfarin sodium (medication to decrease clotting of the blood) and muscle weakness. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 5/8/17, indicated a Brief Interview for Mental Status (BIMS) score of 12 (scores of 13 to 15 indicate the person has intact cognition, scores of 9 to 12 indicate the person has moderate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PX9011 Facility ID: CA070000086 If continuation sheet 2 of 5 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 08/07/2017 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 impairment of cognition), was wheelchair bound and required extensive assistance from staff for activities of daily living and dressing. Review of Resident 1's "Morse Fall Assessment Scale", dated 7/22/17, indicated she had a score of 45 (a score of 45 and higher indicates a high risk for falls). Review of Resident 1's Physician Orders dated 6/19/17 indicated Resident 1 had two upper bed side rails and was using a low air loss mattress (LAL mattress, an alternating pressure air mattress). Review of Resident 1's Interdisciplinary Team Post Fall Review, dated 7/24/17, indicated Resident 1 slid off of her bed as CNA A was in the process of turning her in the bed and pulling up her pants. An interview with Registered Nurse B (RN B) indicated he found the resident lying face down on the floor in a pool of blood coming from Resident 1's right eyebrow. Resident 1 was alert and verbally responsive prior to leaving for the hospital via 911 (emergency services). Review of Resident 1's hospital History and Physical report dated 7/23/17 indicated her computed tomography scan (CT scan, uses Xrays to make detailed pictures of part of the body) of the head and cervical spine showed multiple fractures of her cervical spine and a right facial fracture. The history and physical further indicated a laceration of her right eyebrow. During an interview with CNA A on 7/27/17 at 1:10 p.m., he stated he was dressing Resident 1 at the time she fell off the bed on 7/22/17. CNA A stated Resident 1 was lying on the edge of the bed on her left side facing him, the bed was in the high position at his waist level with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PX9011 Facility ID: CA070000086 If continuation sheet 3 of 5 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 08/07/2017 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 the side rail down. CNA A stated he was standing in front of the resident's hips and upper legs. CNA A stated Resident 1 slipped out of the upper part of the bed head first as he pulled up her pants after the resident's incontinent care. CNA A stated Resident 1 was lying on an air mattress, which was more slippery than a regular mattress, when he moved her in the bed. CNA A stated he had not had any training about caring for someone who is lying on a LAL mattress, or about moving the patient to the center of the bed and away from the edge of the bed. During a phone interview with CNA C on 7/31/17 at 3 p.m., he stated he was Resident 1's evening shift CNA. CNA C stated he always raised the side rail when he cared for Resident A to prevent a fall, and kept her in the center of the bed when turning her. CNA C stated he took extra precaution to prevent a fall because the LAL mattress was slippery and it would become flat under Resident 1's weight, which would make it easy to roll off if she was too close to the edge of the bed. During an interview with the Director of Staff Development (DSD) on 7/27/17 at 2 p.m., she stated she teaches the CNAs to put the residents in the middle of the bed prior to turning them onto their side. The DSD stated CNA A should have had the side rail up to prevent Resident 1 from falling. The DSD stated she teaches the CNAs to place a pillow next to the side rail to prevent the resident from hitting their head when they are turned. Review of the DSD's lesson plan for an inservice, dated 6/6/17, titled "Turning and Repositioning", indicated the CNAs were taught to place the resident in the middle of the bed and to place pillows inside the side rails prior to repositioning. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PX9011 Facility ID: CA070000086 If continuation sheet 4 of 5 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 08/07/2017 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 DSD on 7/31/17 at 4 p.m., she stated CNA A received an inservice similar to the one provided on 6/6/17 during his orientation in January of 2017. The facility provided a copy of the manufacturer's instructions for Resident 1's LAL mattress. The safety information section indicated there was an increased risk of gradual movement and/or inadvertent bed exit with the use of the LAL mattress. It further indicated it would be helpful to activate the Autofirm mode (air deflates from the mattress to achieve a firm mattress for repositioning purposes). Review of the Bedard Pharmacy and Medical Supplies Website (www.BedardMedical.com) indicated there was an increased risk of resident falls with the use of the low air loss (LAL) mattress: failure to use bed rails in raised position could lead to accidental resident falls as air mattresses have soft edges that may collapse when residents roll to the edge of the bed. Resident 1 was transferred to a second acute care facility on 7/27/17 with discharge diagnoses of multiple fractures of the cervical spine, right facial fracture, and pneumonia (infection of the lung). Resident 1 expired on 7/28/17, one day after transfer to the second acute care facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PX9011 Facility ID: CA070000086 If continuation sheet 5 of 5