Other·July 31, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a complaint conducted on 7/26/18. For Complaint CA00593645 regarding Quality of Care and Treatment - Resident Safety, the Department did not substantiate a violation of federal or state regulations. For Complaint CA00594003 regarding Quality of Care and Treatment, federal deficiencies were identified (see F684 and F760). In addition, a "B" citation was also issued. Inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 35302, Health Facilities Evaluator Nurse.

F684 SS=D Quality of Care CFR(s): 483.25

F684 08/24/2018 § 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. This REQUIREMENT is not met as evidenced by: 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: TRTD11 Facility ID: CA070000095 If continuation sheet 1 of 8 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: _______________ 056376 (X3) DATE SURVEY COMPLETED 07/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SANTANA HILLS HEALTHCARE CENTER 1250 S Winchester Blvd 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 observation, interview and record review, the facility failed to ensure one of three residents received necessary care and services (1) when: 1. Staff did not follow hospital discharge medication orders for Resident 1; 2. A certified nursing assistant turned off and on the gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) for Resident 1; 3. Midline intravenous (IV, into the vein) catheter (a 3 to 8 inch long catheter inserted into the peripheral veins of the upper arm for IV medication or hydration) dressing was not changed as ordered for Resident 1. Findings: 1. A review of the acute hospital's Inpatient Medicine Discharge Summary on 7/6/18 indicated for the facility to discontinue synthroid (levothyroxine, a medication used to treat hypothyroidism or under active thyroid) due to Resident 1's thyroid stimulating hormone (TSH, a laboratory test; high TSH indicates under active thyroid) level was not high. It also indicated to continue colace (docusate sodium, a stool softener) 100 mg daily due to Resident 1 having history of gastrointestinal bleed (bleeding in the stomach or the intestines). It also indicated to continue multivitamin (a supplement) daily due to Resident 1's pressure injury (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction). A review of the facility's Admission Orders, dated 7/6/18, indicated levothyroxine 50 microgram (mcg, a unit of measurement). It did not indicate Colace or multivitamin. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TRTD11 Facility ID: CA070000095 If continuation sheet 2 of 8 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: _______________ 056376 (X3) DATE SURVEY COMPLETED 07/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SANTANA HILLS HEALTHCARE CENTER 1250 S Winchester Blvd 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 A review of the facility's July 2018 medication administration record (MAR) on 7/11/18, at 1:18 p.m., indicated Resident 1 was receiving levothyroxine 50 mcg every afternoon since admission on 7/6/18. Multivitamin and colace were not in the MAR. During a concurrent record review and interview with licensed vocational nurse C (LVN C) on 7/11/18, at 1:54 p.m., LVN C stated she did not clarify all of the orders in the discharge summary with the facility's physician. She stated colace and multivitamin were not added on the admission orders and were not added to the MAR. She stated the levothyroxine was also not discontinued per hospital's orders. LVN C stated the facility's physician stated to follow the discharge orders from the hospital. During a concurrent record review and interview with the DON on 7/11/18, at 3:56 p.m., DON stated the nurse has to call the physician and clarify the orders regarding discharge orders from the acute hospital. DON confirmed multivitamin, levothyroxine and colace was not carried out as ordered. 2. During an observation and interview with certified nursing assistant D (CNA D) on 7/11/18, on 9:04 a.m., tube feeding machine was off and the tube feeding formula was not connected to Resident 1's GT. CNA D reconnected the tube feeding formula to Resident 1's GT and turned on the tube feeding machine. CNA D stated Resident 1 just received a bed bath. During a wound observation with CNA D and LVN E on 7/11/18, at 10:00 a.m., the tube feeding was off during wound observation. CNA D then turned on the GT feeding machine after the wound treatment. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TRTD11 Facility ID: CA070000095 If continuation sheet 3 of 8 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: _______________ 056376 (X3) DATE SURVEY COMPLETED 07/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SANTANA HILLS HEALTHCARE CENTER 1250 S Winchester Blvd 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 CNA D on 7/11/18, at 10:21 a.m., CNA D stated she turned off and on the tube feeding machine during care. CNA D stated the residents will choke from the formula if she did not turn off and on the tube feeding machine during care. During an interview with the director of staff services (DSD) at 7/11/18, at 11:39 a.m., the DSD stated the CNAs were not supposed to turn off and on the GT by themselves. The DSD stated the CNAs were supposed to call the nurse to manage the GT. A review of the facility's certified nursing assistant job description, 1/1/2009, did not include management of GT feeding. 3. During an observation on 7/11/18, at 9:04 a.m., Resident 1's left upper arm had an intravenous access with the date and time 7/5/18 1440. During an observation and interview with the assistant director of nursing (ADON) on 7/11/18, at 10:30 a.m., she stated the dressing for the IV on the left upper arm of Resident 1 was dated 7/5/18. The ADON stated the last dressing change was done at the hospital and should be changed during admission. A review of Resident 1's clinical record indicated Resident 1 was re-admitted to the facility on 7/6/18. A review of the Resident 1's physician IV orders, dated 7/6/18, indicated a dressing change for a midline IV should be doen 24 hours upon admission or insertion and then weekly or as needed.

F760 SS=D Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2) FORM CMS-2567(02-99) Previous Versions Obsolete

F760 Event ID: TRTD11 08/24/2018 Facility ID: CA070000095 If continuation sheet 4 of 8 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: _______________ 056376 (X3) DATE SURVEY COMPLETED 07/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SANTANA HILLS HEALTHCARE CENTER 1250 S Winchester Blvd 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 must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents are free from significant medication error for two of three residents (2 and 1) when: 1. Licensed staff did not clarify the correct dose and concentration of morphine (a controlled medication used to treat moderate to severe pain) and administered 20 milligrams (a unit of measurement for weight) of morphine sulfate to Resident 2 instead of 1 mg as ordered by the physician. 2. Licensed staff did not clarify the correct time and administered a second dose of intravenous (IV, into the vein) antibiotic (a medication used to treat infections) on the same day to Resident 1 instead of the following day. This failure had the potential to affect the health and well-being of residents. Findings: 1. During an observation and interview with licensed vocational nurse A (LVN A) on 7/24/18, at 4:50 p.m., he stated Resident 2 had two bottles of morphine sulfate with two different concentrations. One unopened bottle of morphine 10 mg per 5 ml (or 2 mg per 1 ml) delivered on 6/19/18 and one opened bottle of morphine sulfate 100 mg per 5 ml (or 20 mg per 1 ml) delivered on 5/22/18 were in the locked narcotic compartment of the medication cart. A review of Resident 2's clinical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TRTD11 Facility ID: CA070000095 If continuation sheet 5 of 8 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: _______________ 056376 (X3) DATE SURVEY COMPLETED 07/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SANTANA HILLS HEALTHCARE CENTER 1250 S Winchester Blvd 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 indicated Resident 2 was re-admitted from an acute hospital on 6/18/18. A review of the facility's paper form titled "Admission Orders," dated 6/18/18, indicated Resident 2 had an order of morphine sulfate 1 ml by mouth every 4 hours as needed for respiratory distress and shortness of breath. It also indicated an order of morphine sulfate 10 mg by mouth every 6 hours as needed for severe pain. The facility's admission orders were signed by a physician on 6/21/18. A review of the facility's electronic health record titled "Order Summary Report," dated 6/18/18, indicated Resident 2 had an order for morphine sulfate solution 1 mg per ml by mouth every four hours as needed for shortness of breath and respiratory distress. It also indicated Resident 2 had an order for morphine sulfate solution 10 mg per ml every 6 hours as needed for severe pain. A review of the facility's MAR for June 2018 indicated Resident 2 received morphine sulfate 1 ml (20 mg) for shortness of breath/back pain on 6/28/18 and 6/29/18. A review of the facility's MAR for July 2018 indicated Resident 2 received morphine sulfate 1 ml (20 mg) for back pain on 7/7/18 and 7/9/18. It also indicated Resident 2 received 1 ml (20 mg) on 7/1/18, 7/9/18 and 7/21/18 for shortness of breath. During a telephone interview with the consultant pharmacist (CP) on 7/24/18, at 4:50 p.m., CP stated the morphine sulfate with the concentration of 20 mg per ml was too strong of a concentration for the 1 mg dosage required for shortness of breath. CP stated the nurse would need to draw 0.05 ml of the morphine sulfate and it would be too hard to measure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TRTD11 Facility ID: CA070000095 If continuation sheet 6 of 8 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: _______________ 056376 (X3) DATE SURVEY COMPLETED 07/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SANTANA HILLS HEALTHCARE CENTER 1250 S Winchester Blvd 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 and administer due to the high concentration. During a concurrent record review and interview with licensed vocational nurse B (LVN B) on 7/24/18, at 5:04 p.m., LVN B stated she did not call the acute hospital to clarify Resident 2's admission orders on 6/18/18. LVN B stated she called the physician to make clarifications but only told the physician what medications the acute hospital ordered for Resident 2 but did not clarify any the dosages or concentrations for the morphine sulfate. LVN B stated she was unable to say how many milligrams nurses were supposed to give for the morphine sulfate 1 ml every four hours for shortness of breath. During a concurrent record review and interview with the director of nurses (DON) on 7/24/18, at 5:38 p.m., DON stated the admission orders for morphine sulfate were incomplete. DON stated the order in the EHR indicated Resident 2 had an order for morphine sulfate 1 mg per ml and the nurses were administering 20 mg per ml. 2. A review of the Resident 1's clinical record indicated Resident 1 was re-admitted to the facility on 7/6/18 from an acute hospital. A review of the acute hospital's MAR indicate Resident 1 received a dose of ertapenem (an antibiotic) 1 gram (g, a unit of measurement for weight) via IV at on 7/6/18 at 8:26 a.m. A review of the facility's Physician's IV orders dated 7/6/18 indicated Resident 1 had an order for ertapenem 1 g every 24 hours via IV which was started on 7/5/18 until 7/12/18. A review of the facility's July MAR indicated Resident 1 received ertapenem 1 g via IV on 7/6/18 at 10:00 p.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TRTD11 Facility ID: CA070000095 If continuation sheet 7 of 8 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: _______________ 056376 (X3) DATE SURVEY COMPLETED 07/26/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SANTANA HILLS HEALTHCARE CENTER 1250 S Winchester Blvd 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 record review and interview with licensed vocational nurse C (LVN C) on 7/11/18, at 1:54 p.m., LVN C stated the admission orders from the acute hospital indicated to continue the ertapenem 1 g every 24 hours via IV which was started at the acute hospital. She stated Resident 1 received a dose of ertapenem 1 g at 10:00 p.m. on 7/6/18 in the facility. LVN C stated she did not clarify the last time the dose was administered. LVN C also stated they have to clarify orders in the discharge summary. During a concurrent record review and interview with the DON on 7/11/18, at 3:56 p.m., DON stated the nurse has to call the physician and clarify the orders regarding discharge orders from the acute hospital. A review of the facility's undated policy and procedure titled "Medication Administration Policy and Procedure indicated "Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition ..., the nurse [should call] the physician for clarification prior to the administration of the medication." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TRTD11 Facility ID: CA070000095 If continuation sheet 8 of 8