Other·April 2, 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 a facility reported incident conducted on 3/27/19. For Facility Reported Incident CA00628924 regarding Quality of Care/Treatment, a federal deficiency was identified (see F600). In addition, a Class "B" citation was 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: 37409, Health Facilities Evaluator Nurse.

F600 SS=D Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; 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: WZEB11 Facility ID: CA070000626 If continuation sheet 1 of 3 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 03/27/2019 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 This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure Resident 1 was free from abuse when certified nursing assistant A (CNA A) yelled at Resident 1 during and after giving Resident 1 shower. This failure had the potential to cause emotional distress and impact the mental well-being of the resident. Findings: Review of Resident 1's Admission Record indicated she was admitted with diagnoses including psoriasis vulgaris (a skin condition that speeds up the life cycle of skin cells; it causes cells to build up rapidly on the surface of the skin; the extra skin cells form scales and red patches that are itchy and sometimes painful.) Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 3/11/19, indicated Resident 1 was cognitive intact; she was total dependence for bathing and needed extensive assistance with oneperson physical assist for personal hygiene. Review of Resident 1's Change of Condition Progress Notes, dated 3/15/19 at 4:55 p.m., indicated while in the shower room, Resident 1 asked CNA A to wash/rinse her hair more, but CNA A was angry and yelled at her "No, it's late." CNA A also told Resident 1 "I don't care." During an interview with Resident 1 on 3/25/19 at 9 a.m., she stated after shower she felt itchy at the perineal area and the buttock. Resident 1 asked CNA A to apply some cream for her, but CNA A was angry and yelled at her "No" and something that Resident 1 stated she did not understand. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WZEB11 Facility ID: CA070000626 If continuation sheet 2 of 3 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 03/27/2019 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 an interview with CNA B, on 3/26/19 at 9:10 a.m., she stated CNA A asked her for help with Resident 1 after the shower. During the changing, Resident 1 asked for the cream to be applied for her, but the cream was not available. CNA A was frustrated and yelled at Resident 1, "There is no cream. I just dress you up just like that." CNA B stated she told CNA A to lower her voice, and CNA A yelled "I don't care." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WZEB11 Facility ID: CA070000626 If continuation sheet 3 of 3