Other·February 3, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding an investigation of a complaint conducted on 1/29/2020. For Complaint CA00671048 regarding Admission, Transfer And Discharge Rights, a federal deficiency was identified (see F623). A Class 'B' Citation was also issued. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 38068, Health Facilities Evaluator Nurse.

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in 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: 2DCM11 Facility ID: CA070000089 If continuation sheet 1 of 7 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 01/29/2020 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 accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2DCM11 Facility ID: CA070000089 If continuation sheet 2 of 7 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 01/29/2020 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 submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2DCM11 Facility ID: CA070000089 If continuation sheet 3 of 7 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 01/29/2020 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 Based on interview and record review, the facility failed to provide a written notice and notified the Long Term Care Ombudsman (LTC Ombudsman, an organization that routinely visits the facility and advocate on behalf of the residents) prior to discharge from the facility for 1 of 3 sampled residents (Resident 1) which resulted in Resident 1 and his family member unprepared for discharge that caused Resident 1's emotional distress. This failure violated Resident 1's rights to file an appeal before his discharged and deprived him an access to an advocate who could inform him of his options and rights regarding his discharged from the facility. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on 9/6/19 with diagnoses that included acute osteomyelitis (infection of the bone) of left ankle and foot, bacteremia (presence of harmful germs in the blood), local infection of the skin and subcutaneous tissue (tissue under skin), and absence of right leg below knee. He received antibiotic therapy (use of antibiotics to treat, prevent, or improve illness). He was selfresponsible (resident made decisions for his own medical care and treatment) and was discharged from the facility on 1/10/2020. Review of Resident 1's minimum data set (MDS, an assessment tool) dated 12/14/19, indicated his cognition was intact. He was independent in bed mobility, transfers, and eating. He required limited assistance in dressing and toilet use, and needed supervision only in personal hygiene and locomotion on unit. Review of the post physical and occupational therapy (PT/OT) program summaries dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2DCM11 Facility ID: CA070000089 If continuation sheet 4 of 7 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 01/29/2020 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 9/25/19, indicated Resident 1 achieved the highest practicable level and was discharged from OT/PT services. Review of Resident 1's physician order dated 10/29/19, indicated "okay to discharge with medications and recent labs". Review of Resident 1's clinical record indicated there was no evidence that the 30 days notice of proposed transfer/discharge was provided to Resident 1 and the ombudsman was not notified from the date the physician ordered Resident 1 was okay for discharge on 10/29/19. Review of Resident 1's clinical record indicated another physician order dated 1/9/2020 to discharge home with wound care, home health registered nurse for two weeks and medications and appointment with primary care physician (PCP). Further review of Resident 1's progress notes records dated 1/10/2020 at 1:54 p.m., indicated the facility told Resident 1 and his family member, who was to return to town on Sunday (1/12/2020), to take Resident 1's items immediately that day from Resident 1's room because the facility needed Resident 1's room. Resident 1 refused for his stuff to be packed up and be kept by the facility in a secure placed until Sunday (1/12/2020). Resident 1 wheeled himself right out the front door of the facility angry and cursing in another language. During an interview with the Resident 1's case manager (CM, a staff who assists in the planning, coordination, monitoring, and evaluation of medical services for a patient with emphasis on quality of care, continuity of services, and cost-effectiveness) on 1/10/2020 at 2:45 p.m., she stated she did not issue a 30 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2DCM11 Facility ID: CA070000089 If continuation sheet 5 of 7 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 01/29/2020 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 day written notice of proposed transfer/discharge to Resident 1. During an interview with the social service worker (SSW, a staff who works on patient education, make referrals for mental health services and coordinate discharge planning when discharge is an option) on 1/10/2020 at 4:06 p.m., she stated the facility did not issue a 30 day written notice of proposed transfer/discharge for Resident 1. During a follow-up interview with the SSW on 1/13/19 at 2:30 p.m., she stated the LTC Ombudsman was not notified prior to Resident 1's discharged on 1/10/2020. During a follow-up interview with the CM on 1/13/2020 at 2:45 p.m., she stated she saw the physician's order for Resident 1 "okay" to be discharged from the facility on 10/29/19 but did not process it because the resident refused to be discharged home. Review the facility's policy and procedures dated 4/7/03, "indicated the transfer and discharge process must provide sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility. At least 30 days prior to transfer or discharge, notify the resident, and if known, the family member, surrogate, or resident representative of the transfer and the other reasons for the move. Provide the information in writing in writing and the language and manner they understand. Explain the resident's right to appeal the transfer/discharge. Provide the name, address, and phone number of the state long term care ombudsman." Review the facility's policy and procedures dated 9/23/03, "Social Services Manager: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2DCM11 Facility ID: CA070000089 If continuation sheet 6 of 7 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 01/29/2020 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 Essential Duties and Responsibilities", indicated coordinates discharge planning. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2DCM11 Facility ID: CA070000089 If continuation sheet 7 of 7