Other·March 15, 2019

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 complaint conducted on 3/15/19. For Complaint CA00623721 regarding Admission, Transfer and Discharge Rights, a federal deficiency was identified (see F660). 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: 34432, Health Facilities Evaluator Nurse.

F660 SS=D Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 03/20/2019 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the 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: ZZCB11 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 03/15/2019 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 development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZCB11 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 03/15/2019 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 quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to meet the discharge needs of one of three sampled residents (Resident 1) when Resident 1, who required 24-hour supervision, was discharged without the 24hour supervision provided in the home. This failure resulted in Resident 1 being found home alone, with a limited and confused response. Findings: During an interview with an anonymous complainant on 2/12/19 at 11:45 a.m., he/she stated Resident 1 was found alone in her home on 2/7/19, lying on her sofa, confused and lying in wet incontinence (not able to control the flow of urine) briefs. Complainant stated Resident 1 had difficulty getting up off of the sofa, was unable to change her brief without assistance, and was intermittently disoriented. Complainant stated the caregiver is with the Resident 1 part of the day, but not overnight. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZCB11 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 03/15/2019 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 During a review of the clinical record for Resident 1, the "Admission Record" indicated she was admitted to the facility on 1/8/19 with diagnoses of encounter for aftercare (after hospitalization for a fall), difficulty walking and history of falls. Review of Resident 1's "Minimum Data Set (MDS, an assessment tool)" dated 1/15/19 indicated her vision was severely impaired: no vision or sees only light, colors or shapes; eyes do not appear to follow objects. Review of the "Initial History and Physical" written by her physician, dated 1/12/19 indicated she did not have full capacity but had a fluctuating capacity to understand and to make decisions. Review of the "Physical Therapist (PT) Progress and Discharge Summary (PTPDS)," dated 2/1/19, indicated a recommendation for Resident 1 to return home with a 24-hour caregiver. PTPDS indicated Resident 1 required supervision to safely transition from lying down to a sitting position and required stand-by assistance (close enough to reach patient) to safely transition from a sitting to a standing position. Review of the "Occupational Therapist (OT) Progress and Discharge Summary (OTPDS)," dated 2/1/19, indicated Resident 1 had not met her long term goal for self-care in the home in order to return home alone safely. OTPDS indicated Resident 1 required supervision for toileting. Review of the "IDT Post-Discharge Plan of Care/Recapitulation of Care," dated 2/2/19 indicated Resident 1 was discharged to home on 2/2/19 with a referral for home health care, and would be living alone with the help of a part-time care-giver (CG) and family who would visit periodically to ensure safety. The same FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZCB11 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 03/15/2019 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 document indicated Resident 1 required some assistance with bathing, dressing, oral care, toileting and eating. During an interview with the director of social services (SSD) on 2/12/19 at 9:25 a.m., she stated Resident 1's responsible party was not completely at ease with Resident 1's discharge to home. During an interview with the director of rehabilitation (DR) on 2/12/19 at 11:15 a.m., she stated the staff in her department (PT and OT) thought Resident 1 was safe to go home with a 24-hour-per-day caregiver. DR stated the department of rehabilitation would not have discharged Resident 1 if they had known she did not have a 24-hour-per-day caregiver. DR stated it was discussed during the interdisciplinary team (IDT) meeting Resident 1 had 24-hour care at home. During an interview with registered nurse unit manager (RNUM) on 2/12/19 at 1 p.m., she stated she represents nursing on the IDT team. RNUM stated it was discussed in Resident 1's discharge IDT meeting, Resident 1 would be discharged to home with a 24-hour caregiver. RNUM stated, the IDT team was very clear about the plan for 24-hour care or it would not be a safe discharge. During an interview with the SSD on 2/12/19 at 12 noon, she stated Resident 1's responsible party told her they were looking into 24-hour care but there was no definite statement Resident 1 would have 24-hour care when discharged to home. SSD stated based on information given to her by Resident 1's responsible party, she thought Resident 1 needed 24-hour care. SSD stated she agreed Resident 1's discharge was not safe without having 24-hour supervision. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZCB11 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 03/15/2019 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 Review of the facility's undated policy, "Transfer and Discharge", indicated the facility should provide a complete, safe, and appropriate discharge plan ... when the facility anticipates a resident's discharge to a lower level of care (private residence) the interdisciplinary team (IDT) with the assistance of the resident and his/her personal representative will develop a discharge plan ... will assist in determining: ... identification of post-discharge needs (e.g. personal care) and preparation needed by the resident and or family/responsible party for discharge. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZZCB11 Facility ID: CA070000626 If continuation sheet 6 of 6