Other·January 2, 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 an entity reported incident and/or a complaint on 11/28/17, 11/29/17, and 12/20/17. For Entity Reported Incident CA00562363 regarding Quality of Care/Treatment - Resident Meds Improperly Administered, a federal deficiency was identified (see F658). In addition, a Class "B" Citation was issued. Inspection was limited to the specific entity reported incidents and complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 10673, Health Facilities Evaluator Nurse; 35302, Health Facilities Evaluator Nurse.

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 01/02/2018 §483.21(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. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide services according to LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BM6011 Facility ID: CA070000626 If continuation sheet 1 of 6 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 12/20/2017 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 the accepted standards of clinical practice when one licensed vocational nurse A (LVN A) who was the charge nurse at Nursing Station A and who prepared medications for residents and placed the medications in meal trays for certified nursing assistants to administer with meals. This failure resulted in one sampled resident (1) to receive the wrong medications. Findings: A review of Resident 1's clinical record indicated she had diagnoses of Alzheimer's disease (degenerative condition that includes gradual impairment in memory), hypertension (high blood pressure), osteoporosis (weak brittle bones), and macular degeneration (a painless eye condition that causes you to lose central vision, usually in both eyes). A review of Resident 2's clinical record indicated she had diagnoses of dementia (degenerative condition that includes gradual impairment in memory), hypertention, diabetes (high blood sugar), and cerebral infarction (stroke). A review of Resident 1's physician orders indicated Felodipine (a blood pressure medication), Preservision (a supplement for vision), calcium (a supplement for osteoporosis) and vitamins in the morning. It also indicated she receives Aricept (a medications to treat confusion in the afternoon). A review of Resident 2's physicians orders indicated aspirin (a blood thinner medication), Cozaar (Losartan, a blood pressure medication), Glucophage (Metformin, a blood sugar medication), Namzaric (MemantineDonezepil, a medication to treat confusion in Alzheimer's), and Vitamin D3 (a supplement) in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BM6011 Facility ID: CA070000626 If continuation sheet 2 of 6 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 12/20/2017 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 the morning. It also indicated she receives Sanctura (Trospium, a medication for overactive bladder) in the afternoon. A review of the medication administration record for Resident 1 dated 11/26/17 indicated all medications for morning were given except for Felodipine. A review of the medication administration record for Resident 2 dated 11/26/17 indicated all morning medications were given. A review of Resident 1's nurses notes dated 11/26/17 at 8:18 a.m., indicated Resident 1 received Glucophage (medication for diabetes), Cozaar (medication for blood pressure), and Flomax (medication for enlarged prostate). A review of the Resident 1's nurses notes dated 11/26/17 at 3:42 p.m., indicated licensed vocational nurse A (LVN A) notified nursing supervisor J (NS J) around 8:30 a.m. reporting that Resident 1 received Glucophage, Cozaar, and Flomax. It indicated licensed nurse on duty was to continue monitoring Resident 1 for any signs and symptoms of hypoglycemia (low blood sugar) and hypotension or hypertension (low or high blood pressure). During a phone interview with LVN A on 11/28/17 2:01 p.m., he stated medications for Resident 2 were given to Resident 1. During the incident, he stated he spoke with certified nursing assistant B (CNA B) that he was waiting for the meal tray of Resident 1 while preparing another resident's medication. He stated he was distracted by another resident who had concerns. When he was done talking to the resident, he stated CNA B came back and said the medication was given to Resident 1. He stated CNA B took the medication from his cart and administered it to Resident 1 which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BM6011 Facility ID: CA070000626 If continuation sheet 3 of 6 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 12/20/2017 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 was intended for Resident 2. During a phone interview with CNA B on 11/28/17 at 2:55 p.m., she stated they were passing trays in the dining room for breakfast and she was not familiar with the residents because she was a part-timer. She stated that she got the tray for Resident 1 and another CNA told her that Resident 1 ate in her room. She stated LVN A heard the conversation and talked to her. She stated LVN A told her to give the medications first before the meal so that Resident 1 could finish the medication first. She stated she looked at Resident 1's meal tray and did not see any medication. She stated she saw the meal tray for Resident 2 in the meal cart and saw medications on the tray and thought it was for Resident 1. She stated she fed Resident 1 her breakfast with the medication she took from Resident 2's meal tray. She stated afterwards CNA C came in and told her to give the medication on the tray. She stated she did and CNA B showed her where LVN A would hide the medications under an upside down cup on the tray. She stated she's not suppose to give medication but went with the flow because that was the practice of the unit. She stated LVN A would cover the medications with a cup in the tray and the CNAs would give the medications. She reported it immediately to CNA E because she did not know if Resident 1 would have a reaction to the medications. During several interviews with CNA D, E, F, G, H, I, on 11/28/17 and 11/29/17, they stated LVN A was a regular nurse who worked in Nursing Station A in the morning. They stated LVN A passed his medications by putting the medications on the meal trays of the residents and covered them with a disposable cup. Then he would let the CNAs give the medications to the residents with the meals. They stated only FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BM6011 Facility ID: CA070000626 If continuation sheet 4 of 6 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 12/20/2017 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 LVN A would do this practice of medication administration. During an interview with director of nursing (DON) on 11/29/17 at 2:29 p.m., she stated CNAs were not allowed to pass medications and were not allowed to pass medications prepared by the nurse. She stated it was not standard practice and was not the practice of the facility. The facility policy and procedure, "Medication Administration" dated 9/1/17 indicated "medications will be administered by a Licensed Nurse per the order of an Attending Physician..." and "medications must be given to the resident by the Licensed Nurse preparing the medication." A review of the facility's undated job description, "Licensed Vocational Nurse (LVN)," indicated the LVN's responsibilities include administering medications... as prescribed" and "following safety policies when administering medications". It also indicated that LVN's are "responsible for supervision of Certified Nursing Assistants and Nursing Assistants' performance including but not limited to... ensuring assignments are based on qualifications of each staff member." A review of the facility's undated job description, "Certified Nursing Assistant" did not indicate medication administration as part of the duties of a CNA. Review of the California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated the nurses' functions include administration, of medications and therapeutic agents necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BM6011 Facility ID: CA070000626 If continuation sheet 5 of 6 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 12/20/2017 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 physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: BM6011 Facility ID: CA070000626 If continuation sheet 6 of 6