Other·July 6, 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 on 6/19/17 through 6/23/17. The facility was licensed for 253 beds. The census at the time of the survey was 228 including 2 bedholds. The sample size was 30. For Complaint CA00539445 regarding Quality of Care and Treatment, the Department did not substantiate a violation of federal or state regulations. For Entity Reported Incident CA00540040, a federal deficiency was identified and a Class "B" citation was issued (see F323). Representing the California Department of Health: 29259, Health Facilities Evaluator Nurse; 38087, Health Facilities Evaluator Nurse; 38174, Health Facilities Evaluator Nurse; 36624, Health Facilities Evaluator Nurse; 36043, Health Facilities Evaluator Nurse; 10673, Health Facilities Evaluator Nurse; 35157, Health Facilities Evaluator Nurse; and 34383, Health Facilities Evaluator Nurse.

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

F248 07/21/2017 (c) Activities. (1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing 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: 3JNY11 Facility ID: CA070000089 If continuation sheet 1 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 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 observation, interview, and record review, the facility failed to provide an ongoing program of activities to support the residents in their choice of activities for two of 30 sampled residents (Residents 6 and 21) and six nonsampled residents (Residents 42, 43, 44, 45, 46, and 47). For Resident 6, the facility failed to provide individualized activities. For Residents 21, 42, 43, 44, 45, 46, and 47, the facility failed to provide a group outing. These failures could affect the physical, mental, and psychosocial well-being of each resident. Findings: 1. Review of Resident 6's clinical record indicated she was bedbound and nonverbal most of the time. Her Minimum Data Set (MDS, an assessment tool), dated 4/6/17, indicated she required total assistance for her activities of daily living. Her individual activity care notes, dated 4/3/17, indicated she would benefit and should participate in room/bedside activities two to three times a week. Resident 6's individual activity notes, dated 4/3/17, indicated the following 1:1 room visit activity interventions: 1. Provide verbal stimulation 2. Provide gentle and appropriate touch to resident 3. Spiritual activities FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 2 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 6's individual activity participation record, dated 6/1/17 through 6/18/17, indicated she refused 1:1 visits for verbal stimulation, gentle and appropriate touch, and spiritual activities. There was no evidence sensory stimulation such as touching her hands, or spiritual activities were provided. Her individual activity participation record indicated incomplete documentation of Resident 6's 1:1 room visit refusals. During an interview with certified nurse assistant S (CNA S) on 6/19/17, at 12:15 p.m., he stated the resident did not respond much to stimulation during care. During an interview on 6/22/17, at 8 a.m., the director of activity (DA) stated bedbound residents were visited three times per week for fifteen minutes. She stated the staff documentation of Resident 6's room visits were incomplete and the current 1:1 room visit activities were not based on Resident 6's preferences. A review of the facility's 7/2007 policy, "One-toOne Activities", indicated to use the interests of the resident as the basis for formatting one-toone activities and to record all one-to-one visits in the daily attendance participation record using the appropriate response code. 2. During the group meeting with residents held on 6/20/17, at 10 a.m., seven of eight resident attendees (Residents 21, 42, 43, 44, 45, 46, and 47) voiced their concerns regarding the group outing. The residents stated the facility did not have a van to take them out for group outings. During an interview with the DA on 6/21/17, at 9 a.m., she stated she could not remember when the facility's van broke down. She stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 3 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 facility bought a new van but it was only used to transport residents their appointments. The DA stated the residents had asked for a group outing such as shopping trips to the mall. She acknowledged she did not follow up with administration regarding the availability of a van or seek alternate transportation options for the group outing. During an interview with Resident 44 on 6/21/17, at 10:30 a.m., she stated since she was a long term resident, it would be nice to go out of the facility once in a while for variety. She also stated they have mentioned the group outing in one of the council meetings. During an interview with Resident 42 on 6/22/17, at 10:20 a.m., he stated he had not gone out for a group outing since he was admitted to the facility. He stated it would be nice to do something different outside of the usual activities. During an interview with Resident 43 on 6/22/17, at 11 a.m., he stated he would love to go on a group outing. He stated after a while, the activities provided by the facilities could be repetitive. A review of the facility's 6/2007 policy, "OffPremises Activities", indicated the Activity Department provides off-premises activities to allow residents to remain a part of the community structure. Off-premises activities include, but are not limited to the following: community plays, church events, concerts, tours, shopping, etc. It also indicated the AD is responsible for arranging transportation to events off-premises and obtaining necessary medical releases.

F257 SS=E COMFORTABLE & SAFE TEMPERATURE LEVELS FORM CMS-2567(02-99) Previous Versions Obsolete

F257 Event ID: 3JNY11 07/21/2017 Facility ID: CA070000089 If continuation sheet 4 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 CFR(s): 483.10(i)(6) (i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81 degrees F. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a comfortable temperature in Nursing Station 5, the hallways leading to Nursing Stations 2 and 3, and in the large dining room when the thermostat (a system which senses the temperature and automatically turns the air conditioner on and off to maintain the desired temperature) was not working. This caused discomfort to the residents. Findings: During an interview with the maintenance manager (MM) on 6/19/17, at 1:12 p.m., he stated there was no cooling system in the facility hallways. During an observation with the MM on 6/19/17, at 1:25 p.m., the thermostat temperature reading were as follows: 1. The thermostat for Nursing Station 5 indicated a temperature of 82 degrees Fahrenheit (F, scale of temperature). The thermostat was set at 70 degrees F. 2. The thermostat for the large dining room indicated a temperature of 83 degrees F. The thermostat was set at 61 degrees F. 3. The thermostat for Nursing Station 3 indicated a current temperature of 82 degrees F. The MM confirmed the three thermostat FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 5 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 reading observations and stated the thermostats were not working. On 6/19/17, at 3 p.m., the survey team informed the administrator (ADM) of the nonworking thermostats, Resident 18's room temperature of 83 degrees F, and her complaint her room was hot. During an interview with the ADM on 6/19/17, at 4:45 p.m., she stated the facility temperature should be maintained between 71 to 81 degrees F. During an interview with the MM on 6/22/17, at 3:45 p.m., he reviewed the facility's preventive maintenance checks binder and was unable to find any documentation regarding when the thermostats were last checked. Review of the facility's 4/15/01 policy, "HVAC Systems Inspection and Maintenance", indicated to record preventive maintenance checks on the appropriate preventive maintenance checklists.

F274 SS=D COMPREHENSIVE ASSESS AFTER SIGNIFICANT CHANGE CFR(s): 483.20(b)(2)(ii)

F274 07/21/2017 (b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition. (For purpose of this section, a “significant change” means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 6 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to determine a significant change in status assessment (SCSA, a significant change is a decline or improvement in a resident's status which will normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, and is not self-limiting) within 14 days for one of 30 sampled residents (Resident 1) when the resident was enrolled in hospice care. This failure could affect the resident's care. Findings: Review of Resident 1's clinical record indicated the resident was admitted to hospice care on 5/22/17 with a terminal diagnosis of end stage renal disease (kidney failure). Resident 1's Minimum Data Set (MDS, an assessment tool) indicated there was no MDS for the SCSA within 14 days after Resident 1 had enrolled in hospice care. During an interview with the registered nurse W (RN W), on 6/20/17, at 9:50 a.m., she stated the SCSA was required when Resident 1 enrolled in hospice care. She also stated the SCSA should have been completed within 14 days from the enrollment date in hospice care. Review of the CMS "RAI Version 3.0 Manual" indicated the SCSA was required to be performed when a resident is receiving hospice services. The ARD must be within 14 days from the effective date of the hospice.

F279 SS=E DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1) FORM CMS-2567(02-99) Previous Versions Obsolete

F279 Event ID: 3JNY11 07/21/2017 Facility ID: CA070000089 If continuation sheet 7 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 483.20 (d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident’s active record and use the results of the assessments to develop, review and revise the resident’s comprehensive care plan. 483.21 (b) Comprehensive Care Plans (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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 8 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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’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 observation, interview, and record review, the facility failed to develop, review, and revise care plans for four of 30 sampled residents (Residents 2, 9, 17, and 22) when: 1. Resident 2's care plan was not revised since readmission. 2. Resident 9's care plan regarding a fall intervention was not reviewed/revised. 3. Resident 17's care plan regarding a fall intervention was not reviewed /revised 4. Resident 22's care plan for an ace wrap (elastic bandage used to decrease swelling) was missing and a dialysis(treatment for kidney failure using a machine to filter the blood outside of the body) readmission care plan was not revised. A care plan identifies the residents' concerns and outlines the care and services needed to meet their needs. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 9 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 1. Review of Resident 2's clinical record indicated she was readmitted in 11/2016 with a history of heart failure, hypertension (high blood pressure), glaucoma (a group of eye conditions that can lead to blindness), and falls. His care plan, dated 12/18/16, included a falling star (indication of a high fall risk resident) for interventions. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC), on 6/20/17, at 9:15 a.m., she confirmed the care plan was last updated in 11/2016 and, when the MDS ( an assessment tool) quarterly review was done in 3/2017, the care plan should have been updated. During an observation on 6/20/17, at 7:40 a.m., Resident 2's name plate on his room did not have a falling star sticker. During an interview with nurse supervisor X (NS X ), on 6/20/17, at 9:30 a.m., she indicated the care plan was not updated for the fall interventions since 12/2016. According to NS X, if a resident had no falls for a long time, the falling star sticker was no longer indicated as an intervention. In this case, Resident 2 should not have a falling star in his care plan. 2. Review of Resident 9's clinical record indicated she had a witnessed fall on 12/16/16, at 11:15 a.m., when she slid out of her wheelchair in front of the nursing station. Her fall risk assessment score was 18 (a score of 10 or above represents a high risk). Resident 9's care plan on falls indicated interventions including a safety reminder device i.e. sensor pad alarm in her bed and in her wheelchair to remind her to ask for assistance before transfers. During an observation on 6/20/17, at 8 a.m., Resident 9 was observed sleeping in bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 10 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 There was no bed alarm and chair alarm noted. During a concurrent observation and interview with certified nurse assistant U (CNA U), she stated Resident 9 had a fall a long time ago and as far as she could remember, the resident never had a bed alarm or a chair alarm. During another observation in the dining/activity area on 6/22/17, at 11:50 a.m., there was no chair alarm attached to Resident 9's wheelchair. The observation was confirmed by the activity assistant director (AAD) and registered nurse W (RN W). During an interview with licensed vocational nurse G (LVN G) on 6/22/17, at 12:15 p.m., she stated Resident 9 should have a bed alarm and a chair alarm as indicated in the care plan. 3. Review of Resident 17's clinical record indicated she had an unwitnessed fall on 1/26/17 and witnessed falls on 3/28/17 and 6/7/17. Her MDS indicated she was cognitively intact. However, her vision was severely impaired. (She stated she had been legally blind since childhood as a result of a car accident). Her fall risk assessment score indicated her risk score was 16 (a total score above 10 represents high risk for fall). There was no fall risk assessments done after the second and third falls. Resident 17's Incident/Accident Post Review (post fall), indicated there was no care plan revision after the third witnessed fall. After the third fall incident on 6/7/17, at 3:48 p.m., Resident 17 came back from the Blind Center accompanied by the transport driver. The witness stated the driver was holding on to the walker while the resident walked up the ramp but the driver walked too fast and the resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 11 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 lost her balance and fell to the floor. Her long term fall care plan did not address any followup regarding education of the transport driver on safe transport of the resident to prevent further falls. There was also no recommendation for a referral for physical therapy after the third fall. During a concurrent interview and record review with LVN F on 6/21/17, at 11:30 a.m., she stated after the third fall, the facility called the transport company and the company stated they will educate the driver on safety of residents. LVN F confirmed the facility did not receive any documentation from the transport company regarding driver education on resident safety. During an interview with the director of staff development (DSD) on 6/23/17, at 9;20 a.m., she stated fall incidents are discussed in the daily meetings attended by department heads including the rehabilitation therapy. The meeting includes discussions regarding care plans, updates, revisions, interventions, and recommendations. The DSD stated fall risks assessments should be completed after each fall. 4. Review of Resident 22's clinical record indicated he was readmitted in 5/2017 with a history of ESRD (end stage renal disease, the last stage of chronic kidney disease necessitating dialysis or a transplant) heart failure, a cerebral infarction (a type of ischemic stroke resulting from a blockage in the blood vessels supplying blood to the brain). Resident 22 has dialysis scheduled every Tuesday, Thursday, and Saturday at 5:30 a.m. During a concurrent interview and record review with LVN P, on 6/22/17, at 10:40 a.m., she stated the care plan, dated 4/6/17 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 12 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 5/5/17, did not match Resident 22's current dialysis schedule and the fluid restriction (limit of the amount of liquids each day) was not updated to match the current order on 5/13/17. LVN P stated in order to update a care plan, she would use a yellow marker and insert a new date. This was not done on Resident 22's care plan. During an observation on 6/23/17, at 8 a.m., Resident 22 was sitting at the edge of the bed eating breakfast and was wearing an ace wrap on both lower legs. A physician order dated 5/26/17, indicated the ace wrap was for compression edema. During an interview and record review with NS X, on 6/23/17, at 8:40 a.m., she was not able to find the care plan for the ace wrap. She stated Resident 22 should have a care plan for the ace wrap. The facility's 11/2011 policy, "Comprehensive Plan of Care", indicated to re-evaluate and modify care plans as necessary to reflect changes in care, service, and treatment. Discontinued care plan interventions should be highlighted with a transparent yellow marker and the discontinued item should be dated and initialed.

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

F281 07/21/2017 (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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 13 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to meet professional standards of quality when physician orders for six of 30 sampled residents (Residents 2, 8, 14, 20, 22, and 27) were not followed. For Resident 2, the orthostatic blood pressure (BP, a form of low blood pressure measurement taken when the resident stands up from a sitting or lying down position) was not taken for two months. For Resident 8, the right heel bootie was not applied as ordered by the physician. For Resident 14, the the physician order for a WanderGuard (small device placed on the ankle or wrist of the resident which alarms to notify the staff if resident tries to leave the facility) was not followed. For Resident 20, medications were not always administered and blood sugars were not checked when the resident was having dialysis. For Resident 22, monitoring of the ace wrap was missing, the application of the ace wrap was not performed according to the physician order, and monitoring of the pacemaker was missing. For Resident 27, her medications were not always given as ordered when she was having dialysis (the clinical purification of blood as a substitute for the normal function of the kidney). These failures had the potential to compromise the residents' health. Findings: 1. Review of Resident 2's clinical record indicated she was readmitted in 11/2016 with diagnoses including heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), hypertension (increase in blood pressure), paroxysmal afib (a type of atrial fibrillation in which the irregular heartbeat occurs every so often), glaucoma (eye disease), and falls. Her physician order, dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 14 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 3/30/17, indicated to monitor postural blood pressure (orthostatic hypotension) during the morning shift. Her Medication Administration Record (MAR) for the month of April indicated there was a nursing initial but no blood pressure taken on 4/11/17, and for the month of May, no blood pressures were taken. During an interview with the licensed vocational nurse Y (LVN Y ), on 6/20/17, at 12:30 p.m., she confirmed the orthostatic blood pressures were missing on the MAR for the months of April and May and the blood pressures should have been taken and recorded. 2. Review of Resident 8's clinical record indicated she had a physician order, dated 3/18/16, to apply a bootie to her right heel while she was in bed. During an observation on 6/19/17, at 5:30 p.m., and on 6/22/17, at 2:45 p.m., Resident 8 was lying in her bed with no bootie on her right heel. During an observation and interview with LVN L on 6/22/17, at 2:48 p.m., she confirmed Resident 8's bootie was not applied to her right heel and the physician order should have been followed. During an interview with the director of nurses (DON) on 6/22/17, at 4 p.m., she stated Resident 8's right heel bootie should have been applied as ordered by the physician. 3. Review of Resident 14's clinical record indicated he had a physician order, dated 6/2017, to place a WanderGuard on his right wrist and monitor the placement every shift. During an observation on 6/20/17, at 8:15 a.m., there was no WanderGuard attached to the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 15 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 certified nursing assistant Q (CNA Q), on 6/20/17, at 8:15 a.m., he stated Resident 14 had tried to leave the facility. The CNA checked both of the resident's wrists and there was no WanderGuard attached to the resident. 4. Review of Resident 20's clinical record indicated she was admitted with diagnoses including end stage renal failure (ESRD, chronic kidney disease), diabetes mellitus (high blood sugar), and was receiving dialysis (a process removing waste and excess water from the blood) every Tuesday, Thursday, and Saturday. Her physician orders, dated 6/9/17, indicated she was to receive Neurontin (medication to relieve nerve pain) 100 milligrams (mg, unit of measurement) three times a day at 9 a.m., 1 p.m., and 5 p.m. Her MAR indicated she did not receive the 1 p.m. doses of Neurontin on 6/10/17, 6/13/17, 6/15/17, 6/17/17, and 6/20/17. Her physician order, dated 5/27/17, indicated Novolog (insulin injection to control diabetes mellitus) was to be injected in the prescribed units as directed per sliding scale before meals three times daily at 6:30 a.m., 11:30 a.m., and 4:30 p.m. The MAR indicated Resident 20's blood sugar was not checked at 1 p.m. prior to the injection of the prescribed units per the sliding scale on 6/1/17, 6/3/17, 6/6/17, 6/8/17, 6/10/17, 6/13/17, 6/15/17, 6/17/17, and 6/20/17. There was no evidence indicating the physician had been informed the medications had not been given. During an interview and record review with infection control nurse A (ICN A) 6/22/17, at 10:35 a.m., he confirmed Resident 20's Neurontin was not administered and her blood sugars were not check on the above dates. He also stated the licensed nurse should have informed the physician and changed the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 16 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 prescribed order. 5a. Review of Resident 22's clinical record indicated he was readmitted in 5/2017 with diagnoses including end stage renal disease (ESRD, the last stage of chronic kidney disease necessitating dialysis or a transplant), heart failure, and a cerebral infarction (a type of stroke resulting from a blockage in the blood vessels supplying blood to the brain). His Minimum Data Set (MDS, an assessment tool), dated 4/13/17, indicated his short term memory was intact. His physician order, dated 5/26/17, indicated to apply ace wraps to both legs for compression edema control. His Treatment Administration Record (TAR) indicated to apply the ace wraps at 9 a.m. and take them off at 9 p.m. There was no documentation of the resident's refusal of the ace wraps on dialysis days. During an observation on 6/22/17, at 11:15 a.m., Resident 22 was up in a wheelchair. His ace wraps were not on both legs. During a concurrent interview with Resident 22, he stated the ace wraps were not on three days ago. He stated the ace wraps were put on at 1 p.m. for five days. He further stated he needed the ace wraps and he wanted them on. During an interview with LVN P, on 6/22/17, at 11:25 a.m., she stated Resident 22 refused the ace wraps on days he went to dialysis. During an observation on 6/23/17, at 8:10 a.m., Resident 22 was sitting at the edge of the bed with the ace wraps on both legs. During a concurrent interview with Resident 22, he stated the ace wraps were applied last night at around 7 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 17 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 nursing supervisor X (NS X ), on 6/23/17, at 8:40 a.m., she noted the swelling in both of Resident 22's lower extremities. She stated monitoring for edema was needed as a nursing measure and she could not find the monitoring on the TAR. She further stated the application time of the ace wraps was not performed according to the physician order. The facility's 3/2000 policy, "Elastic Stockings", indicated to check the resident's toes frequently, noting color, temperature, sensation, swelling, and the ability to move. 5b. Review of Resident 22's clinical record indicated he had a physician order, dated 4/6/17, which included pacemaker orders and a pacemaker care plan was initiated the same day. During an observation with NS X, on 6/22/17, at 2:30 p.m., Resident 22's pacemaker was located in his right upper chest. During an interview with nurse supervisor E (NS E ), on 6/22/17, at 12 p.m., she stated pacemaker monitoring should be in the MAR. She stated she was not able to locate the pacemaker monitoring. During an interview with NS X, on 6/22/17, at 1:55 p.m., she indicated pacemaker monitoring, such as the heart rate, should be documented on the MAR. She was not able to locate the pacemaker monitoring. The facility's 3/2000 policy, "Permanent Pacemaker Care", indicated to record the pacemaker test and pulse rate in the treatment record. 6. Review of Resident 26's clinical record indicated he was admitted to the facility in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 18 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 6/2017 and his physician history and physical, dated 6/16/17, indicated he had diabetes mellitus (a chronic disease associated with abnormally high levels of the sugar glucose in the bloods) as one of the admitting diagnoses. His physician progress note, dated 6/18/17, indicated he was assessed for diabetes mellitus. His clinical record indicated he asked RN R why his blood sugar had not been monitored since he was admitted to the facility. During an interview and record review with RN R on 6/23/17, at 7:05 a.m., she stated she performed a finger stick blood sugar per Resident 26's request. She reviewed Resident 26's clinical record and was unable to find a physician order for finger stick blood sugar. During a concurrent interview with the DON on 6/23/17, at 7:40 a.m., she stated RN R should have obtained a physician order prior to performing the finger stick blood sugar. A review of the facility's 11/2002 policy, "Blood Glucose Tests", indicated physician's orders for blood glucose testing are verified prior to beginning the weekly monitoring cycle. 7. Resident 27's clinical record was reviewed and indicated she was admitted with diagnoses including end stage kidney disease necessitating dialysis on Mondays, Tuesdays, Thursdays, Fridays, and Saturdays. She had physician orders, dated 5/4/17, for Reglan (medication used to treat stomach problems) 10 mg and Renvela (medication used to lower the amount of phosphorus in patients receiving kidney dialysis) 800 mg three times a day at 7 a.m., 11:30 a.m., and 5:30 p.m. Her Medication Administration Record (MAR) indicated she did not receive the 11:30 a.m. doses of Renvela on 5/4/17, 5/6/17, 5/8/17, 5/11/17, 5/18/17, 5/20/17, 5/22/17, 5/23/17, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 19 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 5/24/17, 5/27/17, 5/29/17, 6/6/17, 6/7/17, 6/10/17, 6/11/17, 6/13/17, and 6/15/17, and the 11:30 a.m. doses of Reglan on 5/18/17, 5/20/17, 5/23/17, 5/25/17, 5/27/17, 5/30/17, 6/9/17, 6/10/17, and 6/13/17. There was no documentation indicating the physician had been advised the medications had not been given. During an interview on 6/22/17, at 10:15 a.m., with licensed vocational nurse I (LVN I), she reviewed Resident 27's clinical record and confirmed the resident did not receive the medications on the above dates. She stated there was no documentation indicating the treating physician had been notified the medications were not given. She also stated the nurses should have called the physician in order to have the time of the second dose changed. Review of the facility's 12/18/02 policy, "Physician Orders", indicated physician orders provide a clear direction in the care of the resident. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated RNs should follow the physician orders for a medication regimen necessary to implement a treatment per the physician's order.

F309 SS=D PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 07/21/2017 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 20 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure three of 30 sampled residents (8, 19, and 27) and one nonsampled resident (41) received necessary care and services to maintain the highest well-being. For Resident 8, there was no physician order, assessment, interdisciplinary team (IDT, staff members from different departments who coordinates a resident's care) notes, and care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 21 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 plan for the use of a self release waist belt (a strap for quick release). For Resident 19, the facility did not intervene when pain measures were ineffective. For Resident 27, there was no physician order, assessment, and care plan for the use of a self release waist belt. For Resident 41, there was no pre-restraint assessment done prior to use of the self release seat belt. For Resident 35, there was no assessment done on the use of rubberized gloves. These failures had the potential to cause distress and health complications to the residents. Findings: 1. Review of Resident 8's clinical record indicated she was admitted with diagnoses including dementia (memory problem). Her Minimum Data Set (MDS, an assessment tool), dated 4/15/17, indicated the resident had impaired cognition (problem in memory and thinking skills), required assistance in bed mobility, transfer, and dressing. During an observation on 6/19/17, at 12:55 p.m., and 6/20/17, at 8:05 a.m., Resident 8 was observed with a blue colored belt around her waist while she was sitting in her wheelchair. During an observation and interview with certified nurse assistant D (CNA D) on 6/20/17, at 8:05 a.m., she acknowledged Resident 8 was wearing a self release waist belt daily for a long time and it was tied around her wheelchair. During an observation and interview with nurse supervisor E (NS E) on 6/20/17, at 11:25 a.m., she confirmed Resident 8 cannot remove the self release waist belt on her wheelchair. NS E reviewed Resident 8's clinical record and she stated she cannot find a physician order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 22 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 regarding the self release waist belt. There was no assessment, no care plan, no IDT notes, and no indication regarding the use of a self release waist belt. During an interview with the director of nurses (DON) 6/22/17, at 3:20 p.m., she confirmed Resident 8 had a self release waist belt when she was sitting in her wheelchair. She also stated Resident 8 should have a physician order, assessment, care plan, and IDT regarding the self release waist belt. Review of the facility's 5/1/2009 policy, "Restraints Management (Physical)", indicated the use of a restraint or enabling device must be care planned, documented on quarterly updates/ IDT care conferences notes, and on the weekly risk assessments to reiterate the purpose and use of the device. The IDT will also determine if the device is a restraint or not a restraint. 2. Review of Resident 19's clinical record indicated he was admitted with diagnoses including osteoarthritis (caused by aging joints, symptoms include joint pain and stiffness) and thyroid (butterfly shaped gland at the base of the neck)cancer metastasized (spread to other sites in the body) to the bone with spinal cord compression. His MDS, dated 3/4/17, indicated he was cognitively intact. His physician order, dated 6/2017, indicated Gabapentin (medication used to treat nerve pain)100 milligram (mg, unit of measurement) two capsules, twice a day and Acetaminophen (medication used to treat mild pain) 325 mg, two tablets, every four hours as needed. Resident 19's care plans, dated 6/9/17, indicated he fasts (abstain from all or some kinds of food or drink, as a religious observance) to cleanse his body and decrease FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 23 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 pain. His pain care plan indicated to acknowledge the resident's pain, administer the medication, evaluate the effectiveness and consult with the physician if the pain measures were ineffective. There was no documented evidence the physician was notified when the pain measures were ineffective. During a concurrent interview with Resident 19, he stated he had been in pain since he came to the facility six years and seven months ago. He stated he had pain in his back and legs and the staff were aware he was in pain and did not do anything. Resident 19 stated he was drinking alcohol everyday to relieve the pain. During an interview with licensed vocational nurse I (LVN I), on 6/21/17, at 8:10 a.m., she stated Resident 19 always had pain in his lower extremities. She stated she did not notify the physician about the resident's ineffective pain management. Review of the facility's 8/2010 policy, "Pain Management", indicated to notify the physician if signs and symptoms of pain were observed. 3. Resident 27's clinical record was reviewed and indicated she was admitted with a pacemaker (a small device placed in the chest or abdomen to help control abnormal heart rhythms). A report from her treating physician, dated 5/6/17, indicated she had a pacemaker which was last checked in 3/2013. A care plan was not developed for Resident 27's pacemaker, including the manufacturer or model, the settings, the heart rate range, the date of insertion, the frequency of checks, monitoring the resident's apical and radial pulses daily, and monitoring the resident for chest pain, shortness of breath, dizziness, low blood pressure, an irregular heart rhythm, and changes from the pacemaker's set rate. There FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 24 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 were no physician orders regarding the pacemaker and no other documentation regarding Resident 27's pacemaker parameters, her next scheduled pacemaker check, or indicating the nurses followed the facility's policy for monitoring residents with pacemakers. During an interview on 6/22/17 at 10:15 a.m., with LVN I, the charge nurse, she stated she was not aware Resident 27 had a pacemaker. She also reviewed Resident 27's clinical record and stated she was unable to find a care plan regarding the resident's pacemaker, any physician orders, and any documentation regarding the pacemaker, the pacemaker parameters, and the monitoring of the pacemaker. LVN I stated the above information regarding the pacemaker should be included in a care plan and the pacemaker's effect should have been monitored and documented. A review of the facility's 3/2000 policy, "Permanent Pacemaker Care", and the facility's undated policy, "Permanent Pacemakers", indicated the insertion date, the manufacturer, the model, the lead types, and the programmed settings should be recorded, testing of the pacemaker should be scheduled at regular intervals to determine function of the pacemaker and the battery, vital signs should be recorded to determine the effect of the pacemaker, the resident's apical and radial pulses should be taken daily for a full minute, and the resident should be monitored for chest pain, shortness of breath, dizziness, low blood pressure, and an irregular heart rhythm. A review of the U.S. Department of Health & Human Services' National Heart, Lung, and Blood Institute website, www.nhlbi.nih.gov indicated a pacemaker can stop working FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 25 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 properly over time because the wires get dislodged or broken, the battery gets weak or fails, the heart disease progresses, and other devices have disrupted its electrical signaling. Pacemaker batteries last between five and fifteen years. 4. During the initial tour on 6/19/17, at 8:45 a.m. and accompanied by registered nurse Z (RN Z), Resident 41 was sitting in her wheelchair by the door in her room. She was wearing a seat belt and had a sensor chair alarm. According to RN Z, Resident 41 fell a few days ago. RN Z stated the resident was wearing a self-release seat belt. However, when RN Z asked the resident to release the seat belt, she was not able to do it. Review of Resident 41's clinical record indicated she was admitted in 5/2017 with diagnoses including hepatic failure (liver failure), anemia (low blood count), hypertension (high blood pressure), generalized muscle weakness, and alcoholic cirrhosis of the liver ( irreversible scarring of the liver usually associated with excessive alcohol consumption). Her fall risk assessment score, dated 6/13/17, indicated the resident had a score of 16 (a score of 10 or above indicated a high risk for fall). Her MDS indicated her cognition (mentation) was severely impaired. Her physician order, dated 6/20/17, indicated she was to use the self release seatbelt when she was up in the wheelchair. The order further stated the resident was unable to release the seatbelt on command so the self release seatbelt needed to be off during activities, 1:1 visits, and during activities of daily living (ADLS). A pre-restraint assessment, dated 6/20/17, indicated Resident 41 was unable to remove/release the self release seatbelt on command, so the device was considered a restraint. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 26 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 and chart review with LVN P on 6/21/17, at 9:20 a.m., the physician order initially ordered the use of a self release seat belt, on 6/2/17. There was no pre-restraint assessment done prior to the use of the self release seatbelt on Resident 41, observed during the initial tour on 6/19/17. LVN AA confirmed there was no pre-restraint assessment done. She stated an assessment should be done prior to any use of restraint. A review of the facility's 12/1/05 policy, "Restraint Management", indicated before any restraint is placed on a resident, a Pre-restraint Assessment and/or Side Rail Assessment must be initiated by the Licensed Nurse, which will be reviewed by the IDT. A restraining device can be described as an enabler only when it provides the resident greater function and the resident can remove it independently. 5. Resident 35's clinical record was reviewed. His Minimum Data Set (MDS, an assessment tool), dated 4/18/17, indicated he was cognitively intact. His treatment orders dated 9/5/14 indicated perform "head to toe" skin assessment to all areas of skin. This assessment should be completed every week. His care plan dated 5/2/17 indicated monitor skin during care for bruises, swelling, skin tears, redness, irritation and breakdown. Weekly skin check. During the initial tour observation, on 6/19/17, at 8:45 a.m., with the activity assistant director (AAD), Resident 35 was laying in bed, his left hand had an off-gray and blue colored garden glove on. When asked for consent to show off his gloved hand, Resident 35 consented. He grimaced a lot while he removed his glove. Resident 35's left hand from the wrist down to the fingers, showed a pale-macerated-flakylooking skin. Resident 35's fingernails were long and dirty. This observation was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 27 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 confirmed by the AAD. During an interview, on 6/21/17, at 9:58 a.m., Resident 35 stated he preferred to use the garden glove he bought from orchard gardening. Resident 35 stated the glove put pressure on his hand and reduced the pain. During an interview with the DON, on 6/22/17, at 10 a.m., she reviewed Resident 35's medical record and confirmed there was no skin assessment, and no doctor's notification done about the condition of Resident 35's gloved left hand. Review of the facility's 12/2005 policy, "Skin Care Management", indicated each patient receives the care and services to retain and regain optimal skin integrity. All patients will be checked from "head to toe" weekly by a LN to identify other types of skin breakdown and documents the result in the patient's medical record.

F311 SS=D TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS CFR(s): 483.24(a)(1)

F311 07/21/2017 (a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide treatment and services for one of 30 sampled residents (8). Resident 8 was evaluated by an occupational therapist (OT) and the intervention for restorative nursing assistant (RNA, nursing interventions which assist or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 28 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 promote the resident's ability to attain his or her maximum functional potential) program was not implemented. This practice could result to decline in physical and psychological wellbeing. Findings: Review of Resident 8's clinical record indicated she was admitted with diagnoses including dementia (memory problem) and adult failure to thrive (a decline of function and condition). Her Minimum Data Set (MDS, an assessment tool), dated 4/15/17, indicated the resident had impaired cognition (problem in memory and thinking skills), and required assistance in bed mobility, transfer, eating, and dressing. Resident 8's Occupational Therapy Plan of Care, dated 4/25/17, indicated the reason for the referral was to engage in daily life activities including contracture prevention and promoting range of motion in both hands. The intervention was to discharge the resident to a RNA program. During an interview with the rehabilitation director (RD) on 6/20/17, at 1:30 p.m., she acknowledged Resident 8 was evaluated by the occupational therapist (OT) and she was discharged to RNA program. She confirmed Resident 8 was not referred to the RNA program. During an interview with the director of nursing (DON) on 6/22/17, at 8:25 p.m., she stated Resident 8 had a decline and she was evaluated by the occupational therapist. She stated the OT should have referred the resident to the RNA program to continue the intervention and to prevent functional decline. Review of the facility's undated policy, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 29 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 "Restorative Care Program", indicated to aide the resident to achieve physical, emotional and psychosocial function based on interventions promoting the resident's ability to adapt, and adjust as safely as possible.

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

F323 07/21/2017 (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 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 observation, interview, and record review, the facility failed to provide supervision and adequate assistance for two of 30 sampled residents (Residents 23 and 24), when a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 30 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 physical altercation occurred between the two residents in the smoking area. The incident resulted in Resident 24's fall and Resident 23's acquisition of superficial scratches on his left shoulder blade and left forearm. These failures compromised the residents' safety. Findings: On 6/19/17, at around 5 a.m., Resident 23 went to the smoking patio and saw Resident 24 smoking in the patio. Certified nurse assistant K (CNA K) was present but left when Resident 23 came into the smoking area. According to Resident 23, Resident 24 bumped his wheelchair and tried to choke him. Resident 23 broke free and asked Resident 24 why he was physically aggressive towards him. Resident 23 also claimed Resident 24 was verbally threatening stating, "I'm going to kill you", and also made false accusatory remarks directed towards him. Resident 23 stated Resident 24 came back at him a second time. At this time, Resident 23 in self-defense pushed Resident 24. Resident 24 lost his balance and fell to the floor. Resident 24's clinical record indicated he was a 65 year old male, admitted on 6/2016 with diagnoses including anxiety disorder (a mental disorder characterized by feelings of worry, anxiety, or fear), Parkinson's disease (a disorder of the central nervous system affecting movement, including tremors), multiple sclerosis (MS, a disease of the immune system which affects the protective covering of the nerves), schizophrenia (a chronic and severe mental disorder affecting a person's thoughts, feelings, and behavior), tobacco use, and a history of falling. Resident 24's Minimum Data Set (MDS, an assessment tool), dated 5/7/17, indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 31 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 had moderate independence with decision making but listed a family member as the responsible party (RP, individual legally responsible for decision making). A review of Resident 24's fall risk assessment score, dated 5/7/17 was 16 (a score of 10 and above represents a high risk for fall). The fall risk assessment score after the fall on 6/19/17 was 18. Resident 24's quarterly Safe Smoking Assessment/Evaluation, dated 5/8/17, indicated he was a safe smoker but required supervision as determined by the interdisciplinary team (IDT, a team of health professionals who meet to discuss the resident's care). During an interview with licensed vocational nurse H (LVN H) on 6/22/17, at 7:35 a.m., she stated Resident 24 would sometimes get up early in the morning and would go out to smoke. She stated she was on duty the night of the incident but did not witness the altercation or the fall. LVN H stated Resident 24 would verbalize some delusional thoughts but no physical aggression was exhibited. She stated there should have been a CNA supervising the residents in the smoking area. During an interview with CNA K on 6/22/17, at 3:35 p.m., she stated on 6/19/17 she escorted Resident 24 to the smoking area between 3 a.m. and 4 a.m. She stated initially Resident 24 was fine and then he started to get verbally abusive and accused her of having sex with someone. CNA K felt uncomfortable around Resident 24 and left the smoking area to report Resident 24's behavior to the supervisor. At that time, Resident 23 had already reported Resident 24's fall to the supervisor. CNA K stated someone should have stayed with the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 32 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 telephone interview with registered nurse J (RN J) on 6/23/17, at 7:35 a.m., she stated on 6/19/17, Resident 23 reported Resident 24's fall to her. She stated by the time she went to the smoking area, Resident 24 was already up in his wheelchair. Resident 24 stated he slid out of the wheelchair but did not elaborate on the details. During an interview with Resident 24 on 6/23/17, at 10:30 a.m., he stated he was "okay" but did not want to talk about the incident. He was observed to be very sleepy in his wheelchair. A review of the facility's Smoking Time schedule, indicated the smoking schedule started at 9 a.m. to 9:15 a.m. (15 minutes duration) and repeated at every two hour intervals until 7:45 p.m. to 8 p.m. During an interview with the director of nursing (DON) on 6/22/17, at 3:15 p.m., she stated the facility would allow a resident to smoke outside of the smoking time schedule as long as someone was with the resident for their safety. A review of the facility's "Smoking Policy", revised on 10/2010, indicated the IDT will determine if the resident is a safe smoker and the amount of supervision needed. Safe smoking assessments will be repeated quarterly and whenever there are significant changes in the resident's condition that may affect safety while smoking.

F371 SS=F FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 07/21/2017 (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 33 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 (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 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 foods were stored, prepared, and served under sanitary conditions; two dietary aides had inconsistent responses on how to use the test strip for chemical sanitation (test paper that measures the concentration in part per million (ppm) of the sanitizer in solution; dietary cook did not consistently changed gloves after touching potentially contaminated items before handling food for breakfast trayline; failed to correctly identify the proper mixture of the ice machine cleaning and sanitizing solutions used, and no air gap in the ice machine. These failures created the potential for food-borne illness in a population of 228 residents. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 34 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 1. During the initial tour in the kitchen, on 6/19/17, at 7:45 a.m., with the dietary manager (DM), the following were observed: In the walk-in refrigerator and freezer there were: a. 1 gallon each of opened and undated fresh milk b. 1 plastic bag of opened and undated frozen chicken breast c. 1 plastic bag with 6 pieces of unshelled eggs opened and undated On top of the kitchen shelf, there were: a. 10 boxes of cream of rice undated b. 16 boxes of cream of wheat undated Inside the dry storage bin, there were: a. 5 bags of powdered milk, unpacked, unlabeled and undated. All these observations were confirmed by the dietary manager (DM). In a concurrent interview, the DM stated all opened, unpacked, unlabeled, and undated had "use-by dates"(the last date recommended for use of a product while at peak quality). In another interview with the registered dietician, on 6/21/17, at 9:17 a.m., she stated all opened items should be dated and labeled. 2. During an observation and interview, on 6/20/17, at 8:45 a.m., with dietary aide DD (DA DD), he dipped the test strip into the red bucket, waited for a while then compared the test strip color to the container. During a concurrent interview, when asked how do test strip work, DA DD stated dipped the test strip for 30 seconds then compare. He stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 35 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 reading should be 150 ppm (parts per million). During a concurrent interview with the DM, she stated the test strip should be dipped at least 10 seconds. She also stated 30 seconds or longer is OK. She did not comment on the ppm. 3. In another observation and interview, on 6/21/17, at 9:08 a.m., DA EE dipped the test strip. She was not sure how long to dip the test strip for testing and she was not sure what to do after she dipped the test strip. During a concurrent interview, DA EE stated she dipped the test strip for 15 seconds, then threw it. She stated the test strip color should turn green and the ppm should be 110. 4. In another observation and interview, on 6/20/17 at 9 a.m., cook CC (CK CC) with his gloved hands, picked the sliced bread from the steam table bread container then placed it on the breakfast trayline plates. After several plates, he turned his back away from the trayline, touched the hose of the hot plate holder, grabbed the other bread container and mixed some more sliced bread to the steamtable, then transferred the unshelled boiled eggs to another container using the same gloved hands. CK CC did not remove and change his gloves in between. During a concurrent interview, CK CC acknowledged he should have used the tongs to pick up the bread, used a scoop to transfer the unshelled eggs, and he should have changed gloves and washed hands. During a concurrent interview, the RD stated she would do an inservice to the staff as soon as possible. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 36 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 5. In another observation and interview, on 1/11/17, at 10 a.m., the ice machine did not have an air gap. When asked how often the maintenance manager (MM) cleaned the ice machine, The MM stated he cleaned it monthly. When asked about the ice machine cleanser and sanitizer usage, the MM stated the amount of cleanser and sanitizer to be used should be 1 ounce of bleach and 8 ounces of water. He also stated the cleanser will run for 15 minutes and the sanitizer will run for one hour. The MM also stated the ice machine had an air gap. Per review on 6/28/17 of the following facility's policies and procedures: A review of the 07/2006 Manual pages 17 and 18, "Cleaning, Sanitation and Maintenance", indicated the ice machine's water systems should be cleaned and sanitized a minimum of twice per year. To clean, mix a cleaning solution of 1 oz of ice machine scale remover to 12 ounces of water. To sanitize, mix 1 ounce of liquid household bleach with 2 gallons of warm (95-110 degrees F) potable water. "Air gap" indicated the only way to prevent backflow is to create an air gap. An air gap is an air space that separates a water supply outlet from a potentially contaminated source. "Sanitation and Infection Control" indicated food items will be labeled and dated when placed into containers. New stock must be placed behind the old stock so oldest items will be used first. Products should be dated to assure "FIFO- First In-First Out." Bins holding dry goods must be clearly labeled on the lid and front of the container and dated when the product was put into bin. "Temperature Danger Zone" indicated keeping FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 37 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 cold food cold at 41 degrees F or below is a simple practice that can help eliminate bacterial growth in the kitchen. Perishable foods should be stored less than or equal to 41 degrees F. "Refrigerated Storage" indicated Leftover food or unused portion of packaged foods should be covered, labeled and dated to assure they will be used first. Inservice record attendance titled "How to Use the Sanitizing Bucket" indicated it was last provided on 4/7/2016. Inservice provided on 3/31/17, titled "Food Safety and Sanitation Procedure", indicated CK CC attended the inservice. "Food Preparation", indicated handle food using suitable utensils such as tissue, spatulas, tongs. The Food Code of the U.S. Food and Drug Administration (FDA) classifies ice as food. As such, establishments operating under these guidelines must clean and sanitize their commercial ice machines according to the machine manufacturer's guidelines. "Hydrion Quat Test Papers" indicated for testing n-alky dimethyl benzyl and/or n-alkyl dimethyl ethyl benzyl ammonium chloride. IMMERSE FOR TEN SECONDS COMPARE WHEN WET. Compare the resulting color with the enclosed color chart which matches concentrations of 0-150-200-400-500ppm. Test solution should be between 65 and 75 degrees Fahrenheit. Hydrion QT-40 Quaternary Test Paper provides a simple, reliable, and economical means to measure the concentration of Quaternary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 38 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 Sanitizers, particularly multi-quat broad range quaternary ammonium sanitizer solutions. Test paper measures concentrations between 0500ppm, detecting exhaustion of solutions that should be replaced as well as helping to avoid using excessive amounts of sanitizing agents. Federal, State and Local health regulations require users of Quaternary Ammonium Sanitizer Solutions to have appropriate test kits available to verify the strength of sanitizer solutions. Sanitizer solutions are essential in the food service industry to ensure that sanitizers are at the proper concentration specified by the individual manufacturer.

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

F431 07/21/2017 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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 39 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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) 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, interview, and record review, the facility failed to ensure the controlled substance medications (medications with a high risk for abuse and addiction) were accounted for appropriately for three nonsampled residents (33, 40, and 48), over the counter (OTC) treatments were stored safely for one of 30 samples residents (19) and two non-sampled residents (36 and 37), treatment cart was locked when not in use, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 40 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 emergency drug kit (E-kit) was replaced within 72 hours. These failures had the potential to affect the health and safety of the residents. Findings: 1. Review of Resident 33's Physician Order, dated 6/2017, indicated Lorazepam (medication to treat anxiety) 0.5 milligram (mg, unit of measurement), 1 tablet, daily as needed for anxiety. Review of Resident 33's Controlled Drug Record (CDR), indicated Lorazepam 0.5mg, 1 tablet was taken out on 6/4/17 at 10 a.m., and 6/13/17 at 7:35 a.m. Review of Resident 33's Medication Administration Record (MAR), dated 6/2017, indicated there was no documented evidence Lorazepam was administered to the resident on 6/4/17 and 6/13/17. During an interview with licensed vocational nurse I (LVN I), on 6/21/17, at 8:10 a.m., she stated the medication was given to Resident 33 and forgot to document in the MAR. During an interview with director of nursing (DON), on 6/23/17, at 9:15 a.m., she stated the medication recorded to the CDR should reconcile with the MAR. 2. Review of Resident 32's Physician Order, dated 6/2017, indicated Percocet (medication for pain) 10/325 mg, 2 tablets every 4 hours as needed for breakthrough pain. Review of facility's Emergency Drug Contingency Supply Form (EDCSF), indicated Percocet 10/325 mg, 2 tablets were taken out from emergency drug kit (E-kit) on 6/16/17 to be admistered to Resident 32. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 41 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 3's Medication Administration Record (MAR), dated 6/2017, indicated Percocet was administered on 6/16/17. During an interview with registered nurse R (RN R) on 6/20/17, at 9:20 a.m., she stated the E-kit was opened more than three days and should be replaced within 72 hours after opening. Review of the facility's policy "Emergency Medication Supplies" dated 1/1/13, the emergency medication supply should be maintained either by a mechanism of replacement or exchange, as mutually agreed upon by facility and pharmacy and in compliance with applicable law. 3. During the initial tour on 6/19/17 at 7:40 a.m., Resident 19 had a 500 cubic centimeter (cc, unit of measurement) bottle of isoprophyl alcohol on top of the over the bed table. During a concurrent interview with licensed vocational nurse P (LVN P), she stated isoprophyl alcohol should be kept at nurses station. During a concurrent interview Resident 19, stated he was using alcohol on his arms when itching. Review of the facility's policy "Storage of Medications" dated 4/2007, indicated drugs should be stored in an orderly manner in cabinets, drawer, or carts. Storage area should be accessible to authorized personnel only and inaccessible to residents. 4. During an observation on 6/20/17, at 3:10 p.m., indicated Resident 19 had a bottle of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 42 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 whisky on top of the over the bed table. During a concurrent interview Resident 19, he stated his wife brought two bottles whisky or tequila every week and he keep it with him. Review of Resident 19's Physician Order, dated 6/2017, indicated may take 1-2 of 2 ounces of alcohol per day. During an interview with LVN I, on 6/21/17, at 8:10 a.m., she stated drinking alcohol should be kept at the nurses station. Review of the facility's policy "Alcoholic Beverage" dated 3/2000, indicated the charge nurse receiving the alcoholic beverage must label the bottle with resident's name, room number, exact amount to be administered, the time each amount is to be administered, and the name of the physician. 5. Review of Resident 40's Physician Order, dated 5/20/17 Dilaudid (narcotic medication for pain) 2 mg, one tablet every four hours as needed. Review of Resident 40's CDR, indicated Dilaudid 2 mg, three tablet was taken out on 6/19/17 and three tablet was taken out on 6/18/17. Review of Resident 40's MAR dated 6/2017, indicated Dilaudid 2 mg two tablets on 6/19/17 and one tablet on 6/18/17 administered to the resident. During an interview with LVN C on 6/20/17 at 2 p.m., he stated the medications were administered but forgot to signed the MAR. 6. Review of Resident 48's Physician Order, dated 1/2/17 Norco (narcotic medication for pain) 5 mg-325mg, one tablet every four hours FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 43 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 as needed. Review of Resident 48's CDR, indicated Norco 5 mg-325mg, two tablets taken out on 6/17/17, one tablet taken out on 6/16/17, and one tablet taken on 6/15/17. Review of Resident 48's MAR dated 6/2017, indicated Norco 5mg-325mg one tablet on 6/17/17 was administered. There were no documentation on 6/16/17 and 6/15/17 Norco 5mg-325mg was administered to the resident. During an interview with LVN G on 6/201/7 at 1:30 p.m., she stated the medications were administered but it was not documented on the MAR. During an interview with the infection control nurse A (ICN) A on 6/21/17 at 8:40, she stated the narcotic medication taken out from the CDR should have been reflected on MAR. 7. During the initial tour on 6/19/17, at 8:43 a.m., nonsampled Resident 37 had a 500 cubic centimeter (cc, unit of measure) bottle of hydrogen peroxide on top of his bedside dresser. During a concurrent interview with registered nurse M (RN M ), she stated hydrogen peroxide should not be kept at the bedside. She indicated medications and OTC (over the counter, non-prescription) preparations required a physician order if they are kept at bedside. Review of Resident 37's medical record indicated no physician order to allow hydrogen peroxide at bedside or documentation of Resident 37's ability to self medicate. During an interview on 6/20/17, at 9 a.m., ICN A verified there was no physician order for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 44 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 hydrogen peroxide at bedside. She indicated hydrogen peroxide should be kept at the nurse's station. The facility 2001's policy, revised 04/2007, titled "Storage of Medications", indicated drugs should be stored in an orderly manner in cabinets, drawer, or carts. Storage area should be accessible to authorized personnel only and inaccessible to residents. 8. During initial tour on on 6/19/17, at 7:50 a.m., nonsampled Resident 36 had a 4 ounce jar of Vicks Vaporub on bedside tray table. Review of Resident 36's medical record indicated no physician order to allow Vicks Vaporub at bedside or documentation of Resident 36's ability to self medicate. During an interview on 6/20/17, at 10:05 a.m., licensed vocational nurse P (LVN P ) verified there was no physician order for Vicks Vaporub at bedside. She indicated Vicks Vaporub should be kept at the nurse's station. During an interview on 6/20/17, at 10:10 a.m., registered nurse O (RN O) verified there was no physician order for Vicks Vaporub at bedside. She indicated Vicks Vaporub should not be kept at Resident 36's bedside. The facility 2001's policy, revised 04/2007, titled "Storage of Medications", indicated drugs should be stored in an orderly manner in cabinets, drawer, or carts. Storage area should be accessible to authorized personnel only and inaccessible to residents. 9. During a treatment observation on 6/19/17 at 2:15 p.m., infection control nurse A (ICN A) left treatment cart unlocked and unattended during the entire treatment observation. ICN A positioned the treatment cart close to hallway FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 45 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 wall, and entered a resident's room leaving treatment cart unlocked, unattended, and out of her sight. There were other residents and staff in the hallway during the treatment observation. The following medications were found inside the treatment cart confirmed with ICN A: 1. econazole nitrate cream 1% 2. triamcinolone cream 1% 3. mupirocin cream 2% 4. hydrocortizone cream 2.5% 5. preparation h cream 0.25% During an interview with ICN A on 6/19/17 at 2:30 p.m., she acknowledged treatment cart was left unlocked, unattended and out of her sight. ICN A stated the treatment cart must be kept locked or attended by persons with authorized access. The 3/2000 facility policy titled, "Drug and Biological Storage", indicated to store medications in locked storage area accessible to authorized personnel only... all medication carts must be under visual control of the charge nurse at all times when in use".

F441 SS=D INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 07/21/2017 (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 46 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 47 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain and implement its infection control program when: 1. Resident 31's nebulizer (used to administer medications in the form of mist inhaled into the lungs) mask was not kept in a plastic bag and oudated. 2. Resident 38 received oxygen therapy via undated nasal cannula (a device consist of a lightweight tube which on one end splits into two prongs which a mixture of air and oxygen flow) tubing. 3. A licensed nurse did not clean the table when napkins were in contact with a contaminated surface and used the napkins to wipe Resident 39's eyes after medication was administered. 4. A licensed nurse did not wash his hands after removing his gloves during a medication pass. These practices had the potential to spread infection in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 48 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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: 1. Resident 31's clinical record was reviewed and indicated she had a diagnosis of chronic obstructive pulmonary disease (COPD, a lung disease making it hard to breathe). During the initial tour on 6/19/17, at 7:40 a.m., with licensed vocational nurse P (LVN P), Resident 31's nebulizer mask was exposed to air and dated 6/7/17. During a concurrent interview with LVN P, she confirmed the nebulizer mask was outdated and should kept in a bag when not in use. Review of Resident 31's Physician Order, dated 6/2017, indicated DouNeb (inhalation medication indicated for the treatment of COPD). Review of Resident 31's Medication Administration Record (MAR), dated 6/2017, indicated DouNeb was given on 6/7/17 and 6/11/17. Review of the facility's policy "Nebulizer Theraphy" dated 8/15/02 , indicated place the nebulizer kit in plastic storage bag once treatment is completed. 2. During the initial tour on 6/19/17, at 8:36 a.m., Resident 10 was observed using oxygen at his bedside via (by way of) undated nasal tubing. During a concurrent interview with medical director Q (MD Q), she verified there was no date on the tubing. Review of Resident 10's physician order, dated 3/27/17, indicated to change his oxygen tubing every 5th day when in use. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 49 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 registered nurse N (RN N ), on 6/20/17, at 8:40 a.m., she stated oxygen tubing was changed every five days. She stated the night shift nurses change the tubing and the tubing is dated by the nurse who changed it. The facility's 11/15/2002 policy titled "Cleaning Respiratory Equipment", indicated to replace cannulas used by individual residents within 7 days. When not in use, the cannulas should be stored in plastic bags labeled with the resident's name and date. 3. During a medication pass observation on 6/19/17, at 4:35 p.m., LVN B did not cleaned the table when napkins were in contact with a contaminated surface. LVN B administered eye drops to Resident 39, and used the napkins to wipe eyes after medication was administered. During a concurrent interview, LVN B confirmed he should have clean the table before putting the napkins and used the napkins to wipe Resident 39's eyes. During an interview with the director of nursing (DON) on 6/22/17, at 4:05 p.m., she acknowledged the licensed nurse should have cleaned the table before putting the napkins. 4. During a medication pass observation on 6/19/17, at 4:40 p.m., LVN B removed his gloves after the medication pass and did not wash his hands. During a concurrent interview, he stated he did not wash his hands after he removed his gloves and he continued the medication pass. During an interview with the DON on 6/22/17, at 4 p.m., she stated the licensed nurse should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 50 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 have washed his hands after removing his gloves. Review of the facility's 3/2004 policy, "Standard Precautions", indicated to wash hands immediately after gloves are removed and after resident contacts. All employees are expected to practice standard precautions to reduce the risk of transmitting infections.

F456 SS=E ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION CFR(s): 483.90(d)(2)(e)

F456 07/21/2017 (d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. (e) Resident Rooms Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to maintain a reach-in refrigerator for nourishment in safe operating condition when maximum temperature for cold food was above 41 degrees and the facility failed to ensure a thermometer inside the dry goods storage area was not broken. These failures could potentially affect safe storage of the nourishments in the reach-in refrigerator and the dry goods inside the storage area. Findings: During the initial kitchen tour on 6/19/17, at 8:10 a.m., the reach-in refrigerator for nourishment (maximum for cold food temperature is 41 degrees Farenheit (F), a unit of temperature measurement) temperature was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 51 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 49 degrees F; on 6/20/17, at 11 a.m., it was 48 degrees F then, at 11:10 a.m., it was 51 degrees F. Inside the reach-in refrigerator, there were pitchers of prepared juices, slices of bread wrapped in plastic, prepared individual snacks in small containers, and several individual milk containers. These observations were confirmed by the dietary manager (DM) and the registered dietician (RD). During the concurrent interview, the RD stated food items stored in the reach-in refrigerator will all be placed temporarily in the walk-in refrigerator or be thrown away. During an inspection of the dry storage area, on 6/19/17, at 3:30 p.m., the storage room thermometer was hooked upside down in between the dry goods shelf and was broken. Inside the storage area, there were several canned goods arranged on the shelves and several unpacked boxes. These observations were confirmed by the DM. During the concurrent interview, the DM stated she was not sure when the thermometer was broken. She stated, she will get a new thermometer. In another interview with the RD, on 6/20/17, at 4:28 p.m., she stated moisture and mold will develop and canned food will be spoiled inside the storage room when proper temperature control is not maintained. A review of the facility's 2012 policy and procedure, "Sanitation and Infection Control" subject: canned and dry goods storage: indicated a thermometer should be placed in the storeroom to ensure proper temperature control. A review of the facility's 2012 policy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 52 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 "Temperature Danger Zone" indicated keeping cold food cold at 41 degrees F or below is a simple practice that can help eliminate bacterial growth in the kitchen. Perishable foods should be stored less than or equal to 41 degrees F. "Cleaning refrigerators" indicated verify the refrigerator temperature is less than or equal to 41 degrees F. Food and Drug Administration (FDA) and the United States Department of Agriculture (USDA) indicated on storing foods in the refrigerator are based on refrigerator temperatures of 40 degrees F or lower. FDA and the USDA indicated shelf-stable foods that do not need refrigeration in order to be safe can be kept at room temperature until their "use-by" date. For best quality, store them clean, dry, and cool (below 85 degrees F).

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

F458 07/21/2017 (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 and interview, the facility failed to ensure multiple bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and service the residents receive. Findings: On 6/23/17, at 8:10 a.m., the ADM measured the rooms containing two and three beds. Based on those measurements, the following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 53 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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 rooms had less than the required 80 sq. ft. per bed: Rm No. #of beds/Rm Sq. ft./Rm 108, 109, 303 3 73.6 114, 115, 210, 211 2 76.5 314, 315, 316, 317, 201, 403, thru 208 3 74.0 110, 111, 112, 217, 218, 219, 220 2 74.0 116, 117, 308, 311, 312, 619 2 75.0 309, 310 3 74.3 404, 405, 3 406, 409, 501, thru 509 73.5 407, 408 2 72.9 411, 412, 414, 415, thru 419 2 76.0 510, 511, 515, 516 3 74.8 512, 514, 601, 602, 614, 615 2 71.4 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 54 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 603, 604 3 75.6 609, 610, 611, 612 3 77.0 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Interviews with the staff and the residents indicated the room sizes did not adversely impact the quality of care received by the residents. Recommend continuance of the room size waiver.

F517 SS=D WRITTEN PLANS TO MEET EMERGENCIES/DISASTERS CFR(s): 483.75(m)(1)

F517 07/21/2017 The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to follow the procedure for all potential emergencies when the emergency food was not checked periodically resulting in the expiration of some food items. Failure to discard expired food items could potentially result in the items being served in an emergency and could cause foodborne illnesses. Findings: During an inspection of the emergency food on 6/20/17, at 10:35 a.m., and accompanied by the dietary manager (DM) and the registered dietician (RD), the following expired items were observed: 1. 1 box of gluten free multigrain crackers with a "best before date" of 4/15/17. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 55 of 56 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: _______________ 055318 (X3) DATE SURVEY COMPLETED 06/23/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SKYLINE HEALTHCARE CENTER - SAN JOSE 2065 Forest Ave San Jose, CA 95128 (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. 1 box of gluten free multigrain crackers with a "best before date" of 5/20/17. The 3-day emergency menu inventory supply list was last updated 2/21/17. During a concurrent interview, the DM confirmed the above items were expired and stated they should have been removed from the emergency food supply inventory. Review of the facility's 2012 policy, "Dry Goods Storage Guidelines", indicated it is recommended to follow the "use by date" or the manufacturer's recommendations. A principle of U.S. food law is that foods must be wholesome and fit for consumption. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3JNY11 Facility ID: CA070000089 If continuation sheet 56 of 56