Other·February 7, 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 an abbreviated survey regarding investigation of complaints and entity reported incidents conducted on 12/30/16, 1/23/17, and 2/2/17. For Entity Reported Incident CA00515993 regarding Quality of Care/Treatment, federal deficiencies were identified (see F226 and

F279). For Complaint CA00516435 regarding Quality of Care/Treatment, federal deficiencies were identified (see F226 and F279). For Entity Reported Incident CA00515100 regarding Quality of Care/Treatment a federal deficiency was identified (see F226). For Complaint CA00515170 regarding Quality of Care/Treatment a federal deficiency was identified (see F226). A Class "B" Citation on Abuse/Facility Not SelfReported was issued for F226. Inspection was limited to the specific complaints and entity reported incidents investigated and does not represent a full inspection of the facility. Representing the California Department of Public Health: 29260, Health Facilities Evaluator Nurse.

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

F226 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: W6NN11 Facility ID: CA070000626 If continuation sheet 1 of 9 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: _______________ 555487 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION DE LA CASA NURSING & REHABILITATION CENTER 2501 Alvin Ave San Jose, CA 95121 (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 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to implement the facility's abuse policy when an alleged resident abuse was not reported within 24 hours to the appropriate agencies for one of two residents (Resident 1), and when one staff was not trained annually regarding abuse policies and procedures. These failures had the potential for continued FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W6NN11 Facility ID: CA070000626 If continuation sheet 2 of 9 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: _______________ 555487 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION DE LA CASA NURSING & REHABILITATION CENTER 2501 Alvin Ave San Jose, CA 95121 (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 abuse and harm to the resident by a suspected abuser if the allegation was proven, and failure to maintain annual elder abuse training of policies and procedures for one staff. Findings: 1. Review of form SOC 341 (a form used to report alleged abuse) received by the California Department of Public Health (CDPH) via facsimile on 12/20/16 at 1:23 p.m., indicated an alleged abuse incident occurred on 12/19/16 at 4 p.m. against Resident 1. It indicated voicemail messages were left for the Ombudsman and CDPH on 12/19/16 at 6:50 p.m. It indicated the local police department was notified on 12/19/16 at 5:39 p.m. During an interview on 12/30/16 at 7:30 a.m. with the administrator, he stated Resident 1's family members (FMs) came into the facility for a meeting on 12/19/16 at approximate 3:30 p.m., and informed him staff was showing the resident cell phone videos of a sexual nature, and was inappropriately touching and abusing the resident. Resident 1's skin was checked and no scratch was noted. The administrator stated he found out about the alleged abuse late on 12/19/16 so the SOC 341 was not faxed to CDPH until 12/20/16 at 1:23 p.m. During an interview on 12/30/16 at 1:06 p.m. with Resident 1's family member (FM), he stated on 12/18/16 at 7:50 a.m. the resident was mumbling he did not want certified nurse assistant A (CNA A) caring for him as he was rough with him, threw him on the bed, touched him inappropriately, and scratched him on his abdomen. The FM stated CNA A also invited the resident to watch a pornographic video with him on his cell phone. During an interview on 12/30/16 at 9:12 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W6NN11 Facility ID: CA070000626 If continuation sheet 3 of 9 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: _______________ 555487 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION DE LA CASA NURSING & REHABILITATION CENTER 2501 Alvin Ave San Jose, CA 95121 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with CNA B, she stated on 12/18/16, she was in the room feeding breakfast to Resident 1's roommate when she heard Resident 1 complain (in a language other than English) to his FMs, CNA A scratched him during care and showed him a sex film on his cell phone on Friday, 12/16/16. CNA B replied to Resident 1 and his FMs, if the resident had a complaint he should report it to the licensed nurse supervisor and the social worker on Monday (12/20/16). During a continued interview with CNA B, she stated she would consider it alleged abuse if a CNA was showing a video of a sexual nature to a resident. She stated she reported to registered nurse C (RN C) only that Resident 1's FMs did not want CNA A to care for the resident. She stated she should have informed RN C of the alleged sexual video shown to the resident and the allegation of being scratched on the abdomen by CNA A. During an interview on 12/30/16 at 9:40 a.m. with RN C, she stated Resident 1's FMs came to her on 12/18/16 at approximately 9:30 a.m. and asked for the names of Resident 1's nurse and CNA. She stated she gave a note with licensed vocational nurse D's (LVN D) name and CNA A's name on it. She asked the FMs why they were requesting staff names and was informed CNA A handled Resident 1 roughly, and showed the resident an inappropriate video. RN C stated she was shocked and never had this kind of case. She stated she was not the regular nurse and was not sure what to do. She asked the FM to talk to the supervisor "tomorrow." She stated she considered the allegations potential for sexual and physical abuse, but did not further investigate. During an interview on 12/30/16 at 10:15 a.m. with the social service director (SSD), she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W6NN11 Facility ID: CA070000626 If continuation sheet 4 of 9 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: _______________ 555487 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION DE LA CASA NURSING & REHABILITATION CENTER 2501 Alvin Ave San Jose, CA 95121 (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 stated Resident 1's FMs had a meeting with staff at approximately 3:30 p.m. on 12/19/16, voicing concerns of CNA A touching the resident and showing him pornographic videos. The SSD stated it was after the meeting on Monday, 12/19/16 at approximately 7 p.m. she reported the alleged abuse to the agencies. During an interview on 12/30/16 at 8:50 a.m. with CNA A, he stated he continued caring for Resident 1 on 12/19/16 during the day, as he was his permanent resident. CNA A stated Resident 1 informed him, "[name of ethnic group] are no good," but he was unaware at that time of the FMs and Resident 1's allegation of abuse regarding him. During an interview on 1/23/17 at 12:09 p.m. with RN E, she stated on 12/19/16, she scheduled CNA F to assist CNA A whenever he gave care to Resident 1 so as to witness any comments or concerns the resident might have had. There was no mention by LVN D to RN E regarding the alleged sexual cell phone videos or abuse by CNA A. During an interview on 1/23/17 at 11:54 a.m. with CNA F, she stated on 12/19/16 she and CNA A went together into Resident 1's room twice during the day to change his briefs. During an interview on 1/23/17 at 12:22 p.m. with LVN D, she stated she was informed on 12/19/16 at approximately 8 a.m., Resident 1 did not like CNA A, as he did not take out his garbage or change his bed linens. RN E stated she was not aware of alleged sexual abuse by CNA A until approximately 10:30 a.m., and did not know the extent of it or she would not have assigned CNA A to care for Resident 1 on 12/19/16. Review on 12/30/16 of the facility's 12/12/2014 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W6NN11 Facility ID: CA070000626 If continuation sheet 5 of 9 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: _______________ 555487 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION DE LA CASA NURSING & REHABILITATION CENTER 2501 Alvin Ave San Jose, CA 95121 (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 revised policy "Abuse and Neglect Prohibition Policy" indicated, "All facility staff is identified as mandatory reporters. As mandatory reporters, they will be, and have been, instructed, to immediately report any suspected...abuse to one of the following: Charge Nurse, Immediate Supervisor, Social Services Designee, Director of Nursing or the Administrator." Additionally, they are informed that they will be assisted in calling the allegation of abuse to the Ombudsman and the Department of Health Services immediately. They will also be assisted in completing the SOC 341 as necessary. A report will also be made to the local police department within 24 hours if there was no serious injury. 2. During an interview on 12/30/16 at 8 a.m. with the administrator, he reviewed a complaint from Resident 2 indicating he was hurt during a transfer from his wheelchair to his bed on 12/27/16. He stated Resident 2 complained of left arm pain after certified nurse assistant G (CNA G) picked up Resident 2 by his armpits and transferred him to his bed. During an interview on 12/30/16 at 12:15 p.m. with the director of staff development (DSD), she stated all staff mandatory, annual elder abuse prevention training inservices were completed in January. She reviewed her January, 2016 abuse training attendance record and stated CNA G did not attend. The DSD stated he missed the training and should have attended. It was his responsibility. A review on 12/30/16 of an attendance record dated 12/14/16 for annual mandatory inservice on elder abuse prevention indicated CNA G did not have his training until the end of the year in December, 2016. Review on 12/30/16 of the facility's 12/12/14 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W6NN11 Facility ID: CA070000626 If continuation sheet 6 of 9 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: _______________ 555487 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION DE LA CASA NURSING & REHABILITATION CENTER 2501 Alvin Ave San Jose, CA 95121 (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 revised policy "Abuse and Neglect Prohibition Policy" indicated the facility will train each employee regarding elder abuse prevention policies and procedures on an annual basis.

F279 SS=D DEVELOP COMPREHENSIVE CARE PLANS CFR(s): 483.20(d);483.21(b)(1)

F279 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). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W6NN11 Facility ID: CA070000626 If continuation sheet 7 of 9 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: _______________ 555487 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION DE LA CASA NURSING & REHABILITATION CENTER 2501 Alvin Ave San Jose, CA 95121 (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 (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 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 interview, and record review, the facility failed to implement measures as stated in the care plan to prevent injury when one of two residents (Resident 2) was hurt when certified nurse assistant G (CNA G) was transferring the resident from his wheelchair (WC) to his bed. This failure resulted in increased left arm pain for Resident 2. Findings: Resident 2's clinical record was reviewed on 12/30/16. His minimum data set (MDS, an assessment tool) dated 6/20/16 and 12/16/16 indicated he had left side impairment to his lower and upper extremities. His MDS further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W6NN11 Facility ID: CA070000626 If continuation sheet 8 of 9 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: _______________ 555487 (X3) DATE SURVEY COMPLETED 02/02/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION DE LA CASA NURSING & REHABILITATION CENTER 2501 Alvin Ave San Jose, CA 95121 (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 the resident needed extensive two person physical assistance for transfers (how the resident moves between surfaces including to or from bed, chair, and WC). Review on 12/30/16 of Resident 2's activities of daily living (ADL) care plan dated 5/7/14 indicated, "The resident requires extensive assistance by 2+ staff to move between surfaces as necessary." During an interview on 12/30/16 at 8 a.m. with the administrator, he stated on 12/27/16 when CNA G transferred Resident 2 from his WC to his bed, he picked him up by his armpits and did not get assistance. The administrator stated CNA G was not familiar with the resident or his plan of care to transfer him using extensive assistance of two staff. A review on 1/23/17 of the facility's policy 08/2006 revised "Care Plans - Preliminary" indicated the interdisciplinary team will review the attending physician's order and implement a nursing care plan to meet the resident's immediate care needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W6NN11 Facility ID: CA070000626 If continuation sheet 9 of 9