Other·August 19, 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 recertification survey conducted on 8/8/19. The facility was licensed for 133 beds. The census at the time of the survey was 129. The sample size was 26. A class "B" citation was also issued for F758. Representing the California Department of Public Health: 37686, Health Facilities Evaluator Nurse; 38068, Health Facilities Evaluator Nurse; 39949, Health Facilities Evaluator Nurse; 35157, Health Facilities Evaluator Nurse, and 34383, Health Facilities Evaluator Nurse.

F553 SS=D Right to Participate in Planning Care CFR(s): 483.10(c)(2)(3)

F553 09/07/2019 §483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to: (i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the personcentered plan of care. (ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. (iii) The right to be informed, in advance, of changes to the plan of care. (iv) The right to receive the services and/or items included in the plan of care. 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: V38E11 Facility ID: CA070000013 If continuation sheet 1 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 (v) The right to see the care plan, including the right to sign after significant changes to the plan of care. §483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must(i) Facilitate the inclusion of the resident and/or resident representative. (ii) Include an assessment of the resident's strengths and needs. (iii) Incorporate the resident's personal and cultural preferences in developing goals of care. This REQUIREMENT is not met as evidenced by: 2. Review of Resident 1's clinical record indicated he was originally admitted on 4/17/19 and was self-responsible. The section of Resident 1's clinical record designated for code status (level of interventions the resident wishes to have if their heart or breathing stops) was blank. During an interview with the director of staff development (DSD) on 8/6/19 at 12:28 p.m., she stated if a resident coded (heart or breathing stopped), facility staff would look in the designated area of the clinical record to determine how to proceed. The DSD further explained the resident should have a POLST form (physician orders for life sustaining treatment, document that specifies medical treatments the resident wants during a medical emergency) and the resident's code status should also be reflected in the physician's orders section of the record. The DSD reviewed Resident 1's record and confirmed the section designated for code status was blank. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 2 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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's policy, "Promoting the Right of Self-Determination for Healthcare Decisions and Advanced Healthcare Directives" dated 11/2016, indicated "Each resident and/or legal healthcare decision maker will be provided a mechanism for reaching decisions concerning preferred intensity of care, including the right to forego or withdraw life sustaining treatment." Based on interview and record review, the facility failed to ensure the residents participated in the development and planning of their care for two of eight sampled residents (Residents 175 and 1). 1. For Resident 175, the advance directive plan of care was not discussed during the IDT (coordinated group of experts from several different fields who work together toward a common business goal) care conference and there was no code status in placed. 2. For Resident 1, the code status (level of interventions the resident wishes to have if their heart or breathing stops) was blank in Resident 1's clinical record. These failure leads to the facility unable to react on emergency situations for their unawareness of code status of these residents. Findings: 1. Review of Resident 175's IDT admission Assessment dated 8/1/19, indicated the advance directive was not completed. During an interview with director of resident assessment K (DORA K) on 8/7/19 at 10:10 a.m., she confirmed the IDT met with the Resident 175 during care conference but did not complete the advance directive and there was no code status in the clinical record. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 3 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F656 Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/07/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(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). (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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 4 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to develop and implement care plans for five of 26 sampled residents (Residents 59, 117, 96, 8, and 83) and one non-sampled resident (Resident 71) when: 1. For Resident 59, the facility did not develop a care plan for his left second toe skin issue; 2. For Resident 117, the facility did not develop a care plan for the use of oxygen; 3. For Resident 96, the facility did not develop a care plan for excoriations (torn or worn off skin) to the buttocks; 4. For Resident 8, the facility did not develop a care plan to address her former tracheostomy (surgical opening into the trachea through the neck to allow the passage of air) site; 5. For Resident 83, facility staff did not implement turning and repositioning as indicated on the care plan; and 6. For Resident 71, the facility did not develop a care plan for a pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions). These failures had the potential to result in the residents not receiving the appropriate care necessary to maintain their highest practicable level of health and well-being. Findings: 1. Review of Resident 59's change in condition evaluation dated 7/16/19 indicated, he was noted with redness to the left second toe with a size of 0.4 centimeters (cm, unit of measurement) by 0.4 cm. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 5 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 and concurrent record review with the treatment nurse (TN) on 8/7/19 at 1:20 p.m., the TN confirmed, there was no care plan to addressed his left second toe redness and she stated, he should have one. 2. During observations on 8/6/19 at 8:32 a.m. and 10:52 a.m., Resident 117 was lying on bed receiving oxygen via nasal cannula (flexible tubing placed into the nostrils and connected to an oxygen source). Review of Resident 117's clinical record indicated, he did not have a care plan to address respiratory issues, including the use of oxygen. During an observation and concurrent interview with the director of staff development (DSD) on 8/6/19 at 12:18 p.m., the DSD looked in Resident 117's room and confirmed, he was receiving oxygen. The DSD confirmed, there was no care plan to address respiratory issues, including the use of oxygen. 3. Review of Resident 96's order summary sheet dated 7/3/19 indicated, moisture related excoriation on bilateral buttocks and thoracic (vertebrae) area, cleanse with normal saline, pat dry and then apply A&D (skin protectant) ointment every shift. During an interview with the treatment nurse (TN) on 8/8/19 at 10:01 a.m., the TN confirmed, Resident 96 had excoriation on bilateral buttocks and thoracic area treatment but there was no care plan. The TN stated, the licensed nurse should have initiated the care plan for Resident 96 excoriation on bilateral buttocks and thoracic area. 4. Review of Resident 8's clinical record dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 6 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 8/8/19 at 11:49 a.m. indicated, Resident 8 was admitted on 12/24/18 with diagnoses of chronic respiratory failure and tracheostomy status. Review of Resident 8's physician order sheet dated 7/11/19 indicated, an order for status post tracheostomy site care to clean every shift cleanse with normal saline, pat dry, and cover with dry dressing daily and as needed. During an interview with the director of nursing (DON) on 8/8/19 at 1:56 p.m., the DON confirmed, there was no care plan after decannulation (a process whereby a tracheostomy tube is removed once patient no longer needs it). 5. Review of Resident 83's Braden Scale assessment (an assessment instrument used in predicting an individual's risk in developing pressure related ulcers) dated 4/15/19 indicated a score of 9 (a score of 9 and below indicated high risk in developing pressure sore). During multiple observations on 8/5/19 at 8:02 a.m., 10:04 a.m., 11:40 a.m., 12:51 a.m., and 1:03 p.m., Resident 83 was observed lying on his back in bed. During an interview on 8/5/19 at 1:58 p.m. with the certified nursing assistant F (CNA F), she confirmed, she did not turned Resident 83 from side to side from 8:02 a.m. up to 1:03 p.m. CNA F also stated Resident 83 was totally dependent with bed mobility. Review of Resident 83's nursing care plan (NCP, an outline of the plan of actions that will be implemented during a patients' medical care) dated 1/16/19 indicated, reposition the resident from side to side when in bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 7 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 the DON on 8/7/19 at 9:18 a.m., she stated, CNA F should have repositioned Resident 83 from side to side because Resident 83 was high risk for developing pressure ulcer. 6. Review of Resident 71's clinical record indicated, she had diagnoses including bradycardia (slow heart rate) and pacemaker placement. There was no documentation the nursing care plan was developed for the pacemaker placement. During an interview with the DON on 8/8/19 at 2:10 p.m., she confirmed, there was no care plan developed for the pacemaker placement. Review of the facility's policy, "Care Plan, Comprehensive" dated 12/2017, indicated "Care plans are individualized through the identification of resident concerns, unique characteristics, strengths and individual needs. The policy further indicated, "Care plans become a comprehensive tool for the IDT to utilize as a reference for identified concerns and approaches to establish guidance for meeting resident individual needs."

F657 SS=D Care Plan Timing and Revision CFR(s): 483.21(b)(2)(i)-(iii)

F657 09/07/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be(i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-(A) The attending physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 8 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to revise or update the nursing care plans (NCP, an outline of the plan of action that will be implemented during a patients' medical care) for one of six sampled residents (Resident 52). This failure had the potential for the repeat occurrence of falls for the resident. Findings: Review of Resident 52's clinical record, the Admission Record dated 8/7/19 at 8:38 a.m. indicated, Resident 52 was admitted on 6/8/19 with diagnoses of fracture (broken bone) of lower end of left femur (thigh bone), fall, chronic pain syndrome, hypertension (high blood pressure), and difficulty in walking. Review of the Situation Background FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 9 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 Assessement Recommendation (SBAR) Fall Report dated 6/25/19 at 3:50 a.m. and 7/12/19 at 4:30 a.m. indicated, Resident 52 was found on the floor after trying to get up to go to the bathroom without calling for help. During a concurrent interview and record review with the director of nursing (DON) on 8/7/19 at 1:01 p.m., the DON confirmed, there was no new intervention implemented by the interdisciplinary team (IDT, coordinated group of experts from several different fields who work together toward a common business goal) to prevent falls after the two incidents. Review of the facility's policy and procedures dated 8/2014, "Fall Management: Fall Prevention", indicated review, revise, and evaluate care plan effectiveness at the minimizing falls and injuries during IDT walking rounds and as needed.

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

F658 09/07/2019 §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 observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for two of 26 sampled residents (Residents 1 and 175) when: 1. For Resident 1, the facility did not follow the physician's order for an alternating pressure pad mattress (APP mattress, medical air FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 10 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 mattress that is designed for the treatment and prevention of pressure ulcers); and 2. For Resident 175, the facility did not follow the physician's order for 1.5 liter fluid restriction and did not notify physician when the blood sugar was over 150. These failures had the potential to compromise the residents' health and well-being. Findings: 1. Review of Resident 1's clinical record indicated, he had diagnoses including diabetes (disease that causes high blood sugar), history of other diseases of the circulatory system (system that circulates blood throughout the body), and pressure ulcer (localized damage to the skin and/or underlying tissue as a result of long-term pressure) on his sacrococcyx (tailbone area). Review of Resident 1's minimum data set (MDS, an assessment tool) dated 8/1/19 indicated, he was at risk for developing pressure ulcers. Review of Resident 1's physician's order dated 7/26/19 indicated, he was to have an alternating pressure pad (APP) mattress for preventive measures. During an observation on 8/6/19 at 7:52 a.m., Resident 1 was in bed lying on a regular mattress, not an APP mattress. During an observation on 8/6/19 at 2:06 p.m., Resident 1 was out of bed and his bed was inspected. The bed did not have an APP mattress. During a concurrent observation and interview with the minimum data set coordinator (MDSC) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 11 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 on 8/6/19 at 2:56 p.m., Resident 1 was lying in bed. The MDSC confirmed, Resident 1 was lying on a regular mattress, not an APP mattress. Review of the facility's policy, "Skin Integrity" dated 12/2016, indicated "Application of pressure reduction mattress" as part of the procedure for managing skin integrity issues. 2. Review of Resident 175's clinical record indicated, she had diagnoses including diabetes (increase in blood sugar), muscle weakness, and hypertension (increase in blood pressure). Review of Resident 175's order summary report dated 8/2/19, indicated blood glucose fingerstick monitoring four times daily before breakfast, lunch, dinner, and hours sleep. Call physician if blood sugar was over 150. During an observation and interview with Resident 175 on 8/5/19 at 8:38 a.m., she stated, her blood sugar was low and the physician should have been notified. During an observation and interview with Resident 175 on 8/6/19 at 1:56 p.m., a one liter bottled water of quinine (tonic water used for leg cramps) was seen at her bedside and admitted she was drinking it. Review of Resident 175's order summary report dated 7/31/19 indicated, Resident 175 had a fluid restriction of 1.5 liter per day. During an observation and interview with licensed vocational nurse L (LVN L) on 8/6/19 at 1:58 p.m., she stated, Resident 175 was on fluid restriction and she was not allowed to have one liter bottled water of quinine on her table. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 12 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 the director of nursing (DON) on 8/7/19 at 4:40 p.m. she confirmed, Resident 175 blood sugar was over 150 on 8/3/19, 8/4/19, 8/5/19, 8/6/19, and 8/7/19. The DON confirmed, the physician was not notified. She stated, Resident 175's fluid restriction should have been followed as ordered by the physician.

F677 SS=D ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 09/07/2019 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide personal hygiene and showers for one of 26 sampled residents (Resident 96) who was unable to carry out activities of daily living (ADL's such as personal hygiene, shower, bed mobility, transfer, dressing, eating, and toileting) independently. This failure had the potential to negatively affect the residents physical and psychosocial well-being. Findings: Review of Resident 96's face sheet indicated she had diagnoses of dementia (memory disorder), diabetes (increase in blood sugar), and psoriasis (a skin disease marked by red, itchy, scaly patches). Review of Resident 96's Minimum Data Set dated 4/25/19, indicated the resident had impaired cognition and would required assistance for bed mobility, transfer, dressing, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 13 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 eating, personal hygiene, toileting, and bathing. During an observation on 8/5/19 at 10:10 a.m., Resident 96 has a black substance underneath the fingernails. During an observation on 8/7/19 at 8:30 a.m., Resident 96 was eating with her hands with fingernails still with black substances underneath. During an observation and interview with certified nurse assistant F (CNA F) on 8/8/19 at 8:36 a.m., CNA F confirmed, Resident 96 ate her corn bread using her hands. During an observation and interview with the director of staff development (DSD) on 8/8/19 at 8:47 a.m., the DSD confirmed, Resident 96's 10 fingernails have black substances underneath and the CNA should have cut and clean them on shower days. The DSD stated, Resident 96 scratched herself and used her hands to eat. The DSD also stated, Resident 96 had scheduled showers every Tuesday and Friday. The DSD confirmed, Resident 96 did not get her shower on 8/6/19, 8/2/19, 7/30/19, 7/26/19, 7/16/19, and 7/12/19. The DSD stated, Resident 96 had no history of refusing her showers. Review of the facility's policy, "Accommodation of Needs Positive Practice" dated 2/2016, indicated the facility staff was instructed to meet residents personal, mental, and physical needs. These include personal grooming, socialization, personal clothing of choice, and attempting to honor life routines.

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 09/07/2019 SS=D CFR(s): 483.25(b)(1)(i)(ii) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 14 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement the surgical consult (wound doctor visit) for one of 11 sampled residents (Resident 98)) when the plan of care was to restrict Resident 98's sitting for two hours per day was not followed for the left buttock wound abscess. This failure placed Resident 98 at risk for further skin damage. Findings: Review of Resident 98's clinical record indicated she had diagnoses including contracture (a condition of shortening and hardening of muscles, tendons, or other tissue) of muscle and paraplegia (paralysis of the legs and lower body). Review of Resident 98's Minimum Data Set (MDS, an assessment tool) indicated she had a brief interview for mental status (BIMS, a structured cognitive test) score of 15 (cognitively intact). Resident 98 would required staff assistance with her activity of daily living (ADL) including bed mobility and transfer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 15 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 Resident 98's Braden (a tool to assess the patient's risk for developing pressure ulcer) Assessment dated 10/5/18 indicated she had a score of 14 (a score of 1314 represents a moderate risk for pressure ulcer). Review of Resident 98's eInteract Change in Condition Evaluation dated 11/6/18 indicated, Resident 98 had a skin wound abscess (a collection of pus that has built up within the tissue of the body) on the left buttocks, with minimal discharges, approximately measured 0.8 centimeter (cm, unit of measurement) in length and 0.8 cm in width. The intervention was to turn to sides every two hours, keep clean and dry. Review of Resident 98's surgical consult dated 1/29/19 indicated, Resident 98's skin wound abscess on the left buttocks etiology was pressure injury. The intervention was to offload the wound on the left buttocks. Review of Resident 98's surgical consult dated 2/22/19, indicated Resident 98's skin wound abscess on the left buttocks had undermining (a pocket beneath the skin at the wound's edge) in 2 cm, moderate exudates, 20 percent slough, approximately 4.8 cm length, 1.8 width, and depth 1.8 cm. The intervention was to restrict sitting to two hours per day for now and see how the left buttocks responds. During a wound observation and interview with the treatment nurse (TN) on 8/7/19 at 10:37 a.m., TN took the dressing on the wound on the left buttocks and the dressing was soaked with drainage. The TN stated, the wound on the left buttocks had two undermining on one o'clock with 4 cm, 12 o'clock with 3 cm, depth with 3 cm, length with 2 cm, and width with 1.4 cm. The TN also stated, it was a stage IV pressure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 16 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 ulcer on the left buttocks. During an interview with Resident 98 on 8/7/19 at 10:38 a.m., Resident 38 stated, the nursing staff got her up at 2:00 p.m. using a hoyer lift (a device that helps get someone in and out of bed) and put her back to bed after dinner at 7:00 p.m. During an interview with CNA I on 8/7/19 at 4:29 p.m., she confirmed, Resident 98 was sitting on her wheelchair when she came to work and she put Resident 98 back to bed at around 7:30 p.m. During an observation on 8/5/19 at 1:30 p.m. and 8/7/19 at 5:15 p.m., Resident 98 was seen sitting up on her wheelchair at the dining area. During an interview with the wound doctor (WD) on 8/7/19 at 1:34 p.m., WD stated Resident 98 was sitting in the wheelchair longer which cause damage to the wound on the left buttocks and develop a pressure ulcer. WD stated, he discussed the plan of care to restrict the sitting to 2 hours to the treatment nurse and expected the facility would follow the plan of care to prevent pressure ulcer. WD stated the instruction was listed on the surgical consult and the facility should read it. During an interview and clinical record review with TN on 8/8/19 at 10:40 a.m., TN stated Resident 98 wound on the left buttocks was a stage IV and facility acquired pressure ulcer. TN also stated the wound doctor plan of care to restrict sitting for two hours was discussed during his rounds but was not followed. During an interview and clinical record review with the director of nursing (DON) on 8/8/19 at 3:53 p.m., the DON stated she did not read the wound doctor instructions regarding to restrict FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 17 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 sitting for two hours and the plan of care was not implemented. Review of the 12/2016 policy, "Skin Integrity", indicated to create an on-going process to identify and actively manage risk and/or skin integrity issues, to prevent infection, determine appropriate referrals or interventions to achieve positive clinical outcomes.

F693 SS=D Tube Feeding Mgmt/Restore Eating Skills CFR(s): 483.25(g)(4)(5)

F693 09/07/2019 §483.25(g)(4)-(5) Enteral Nutrition (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and §483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 18 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 the resident would received the correct amount of feeding formula via gastrostomy tube (GT, a device surgically inserted into the stomach through the abdomen used to supply nutrition or liquid medication when clients are unable to take anything by mouth) on a daily basis for one of three sampled residents (Resident 83) when, the specific time to start the feeding daily was not documented. This failure had the potential to put the resident at risk for malnutrition, weight loss, and dehydration. Findings: Review of Resident 83's clinical record indicated, he had diagnoses including dysphagia (difficulty of swallowing) and GT. His physician order dated 5/21/19 indicated Glucerna (liquid nutrition) 1.2 cal via an enteral pump at 65 milliliters (ml, unit of measurement) per hour for twenty hours per day. The time as to when the administration of Glucerna had started was not documented. During a multiple observations on 8/5/19 at 10:04 a.m., 11:40 a.m., and 12: 51 p.m., Resident 83's GT feeding pump was off. During an interview with the licensed vocational nurse C (LVN C) on 8/5/19 at 1:03 p.m., she confirmed, Resident 83's GT feeding was off on the above date and times. LVN C also confirmed, there was no exact time ordered by the physician as to what time the feeding should have started and turned off daily. LVN C admitted, she did not know what exact time she needed to turned on the GT feeding. Review of medication administration records (MAR) for the month July 2019 and August 1-7, 2019, there was no evidence as to what exact FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 19 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 times enteral feeding was started. During an interview with the director of nursing (DON) on 8/8/19 at 8:55 a.m., she confirmed there was no specific times recorded in the MAR regarding what times the feeding was started on the above months. The DON acknowledged, there should have specific time ordered by the physician as to when to start Resident 83's GT feeding daily. Review of the undated facility's policy and procedures, "Enteral Nutritional Therapy, (Tube Feeding): Documentation Guidelines", indicated documentation may include date and time of feeding.

F695 SS=D Respiratory/Tracheostomy Care and Suctioning F695 CFR(s): 483.25(i) 09/07/2019 § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for two of four sampled residents (Residents 55 and 117) when: 1. For Resident 55, the licensed nurse failed to ensure oxygen was administered as specified in the physician's order; 2. For Resident 117, facility staff administered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 20 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 oxygen without a physician's order. These failures had the potential to compromise the residents' health and safety. Findings: 1. Review of Resident 55's clinical record indicated she had the diagnosis of respiratory failure (inability to keep oxygen and carbon dioxide at normal levels). The record also indicated Resident 55 had a tracheostomy (surgical opening into the trachea through the neck to allow the passage of air). Review of Resident 55's physician's order, dated 11/21/17, indicated she was to receive aerosol mist (used to humidify air) via tracheal mask (device place over the tracheostomy) continuously with O2 (oxygen) at 4 liters per minute (LPM, rate of oxygen administration). Review of Resident 55's oxygen therapy care plan, revised on 6/27/19 indicated, "OXYGEN SETTINGS: O2 as ordered." During an observation on 8/8/19 at 11:44 a.m., Resident 55's oxygen concentrator (machine used to deliver oxygen) was set at 2 LPM. During an observation and concurrent interview with licensed vocational nurse E (LVN E) on 8/8/19 at 12:00 p.m., LVN E looked at Resident 55's oxygen concentrator, slightly turned the adjustment knob (used to increase or decrease the oxygen flow rate), and stated it was set at 2.5 LPM. LVN E stated the oxygen concentrator should have been set at 4 LPM. LVN E confirmed she did not check Resident 55's concentrator to ensure the oxygen was administered at the prescribed rate. 2. During observations on 8/6/19 at 8:32 a.m. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 21 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 10:52 a.m., Resident 117 was lying in bed receiving oxygen at 2 LPM via nasal cannula (flexible tubing placed into the nostrils and connected to an oxygen source). Review of Resident 117's clinical record indicated he did not have a physician's order for oxygen. During an observation and concurrent interview with the director of staff development (DSD) on 8/6/19 at 12:18 p.m., the DSD looked in Resident 117's room and confirmed he was receiving oxygen. The DSD explained Resident 117 should have had a physician's order that specified the oxygen flow rate (how many LPM), the device used to administer the oxygen (i.e. nasal cannula), and whether the oxygen was to be administered continuously or only as needed. The DSD reviewed Resident 117's record and confirmed there was no order for oxygen. Review of the facility's 8/2014 policy, "Oxygen Administration", indicated "Check physician's order for liter flow and method of administration."

F698 SS=D Dialysis CFR(s): 483.25(l)

F698 09/07/2019 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 22 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 interview and record review, the facility failed to provide necessary care and services for one of three sampled residents (Resident 173) when licensed nurses did not monitor the fluid intake and follow the physician order regarding the fluid restriction for dialysis (a procedure by a trained professional to remove wastes and excess fluids from the body) resident. This failure had the potential for medical complications and risk for fluid overload. Findings: Review of Resident 173's clinical record indicated she had diagnoses of end stage renal disease (ESRD, a medical condition in which person's kidneys stop functioning), hypertension (increase in blood pressure), and heart failure (failure of the heart to function properly). Review of Resident 173's physician order dated 8/5/19, indicated fluid restriction of 1000 milliliter (ml, unit of measurement) per day. During an observation on 8/5/19 at 8:50 a.m., Resident 173 was sitting on the bed with water pitcher at her bedside table and resident was drinking in a cup with water. Resident 173 dietary slip indicated on fluid restriction of 1000 ml per day. During an observation and interview with Resident 173 on 8/6/19 at 10:51 a.m., Resident 173 stated she drink the water in the pitcher. During an interview with licensed vocational nurse L (LVN L) on 8/6/19 at 2:07 p.m., she stated Resident 173 was on fluid restriction and can not drink more than 1000 ml/day. LVN L stated she should not have a water pitcher at the bedside to monitor the fluid intake. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 23 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 the director of nursing (DON) on 8/7/19/ at 4:59 p.m., the DON stated Resident 173 was on dialysis and should have followed the physician order regarding fluid restriction.

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 09/07/2019 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 24 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 observation, interview, and record review, the facility failed to ensure a proper administration of medication for one of 26 sampled residents (Resident 11) when licensed nurse left the medication at the bedside during medication administration. This failure had the potential to affect the health and safety of the resident. Findings: Review of Resident 11's clinical record indicated she had diagnoses of malignant neoplasm (an abnormal growth that can grow uncontrolled and spread to other parts of the body), muscle weakness, and chronic pain syndrome. Review of Resident 11's Minimum Data Set (MDS, an assessment tool) dated 5/14/19 indicated, she was cognitively intact but would required assistance for bed mobility, eating, transfer, dressing, personal hygiene, and toileting. During an observation on 8/6/19 at 10:58 a.m., Resident 11 was lying in her bed and a cup of medications at the bedside table. During an interview and record review with licensed vocational nurse L (LVN L) on 8/6/19 at 11:00 a.m., LVN L stated she left the medication at the bedside and Resident 11 could take the medications. LVN L stated there was no physician order and there was no care plan to leave the medications at the bed side . LVN L confirmed, there were total of five medications in the cup. During an interview and record review with the director of nursing (DON) on 8/7/19 at 5:04 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 25 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 p.m., the DON stated LVN L should not leave the medications at the bedside and wait until Resident 11 swallowed the medications safely. The DON stated Resident 11 could not take her medication by herself. The DON review the medication administration policy and she stated the LVN L should have waited until the resident consumed the medications.

F758 SS=E Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 09/07/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 26 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure that six out of nine sampled residents (8, 79, 116, 1, 11, and 84) were free from unnecessary psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) when: 1. For Resident 8, the facility failed to monitor and document specific targeted behaviors for psychotropic medication. 2. For Resident 79, the facility failed to monitor and document specific targeted behaviors for psychotropic medication. 3. For Resident 116, the facility failed to provide an accurate indication of the use of an antipsychotic (class of medication primarily used to manage pychosis), monitor and document specific targeted behaviors, and complete an AIMS (Abnormal Involuntary Movement Scale, records the occurrence side effects in residents receiving antipsychotic medication) assessment during admission. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 27 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 4. For Resident 1, the facility failed to monitor hours of sleep and side effects of psychotropic medication. 5. For Resident 11, the facility failed to monitor and document specific targeted behaviors for psychotropic medication. 6. For Resident 84, the facility failed to monitor and document specific targeted behaviors for psychotropic medication. These failures posed the risks of providing the residents with unnecessary psychotropic medications and that would potentially lead in the development of significant side effects. Findings: 1. During a review of the clinical record for Resident 8, the Admission Records dated 8/8/19 at 11:49 a.m., indicated Resident 8 was admitted on 12/24/18 with diagnoses of chronic respiratory failure (is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), bipolar disorder (associated with episodes of mood swings ranging from depressive lows or manic highs) and anxiety disorder (intense, excessive, and persistent worry and fear about every day situation). During a review of the clinical record for Resident 8, the Order Audit Report, dated 8/8/19 at 12:22 p.m., indicated an order for Alprazolam (a psychotropic medication) 0.5 tablet take 0.5 tab (0.25 milligrams) (mg, a unit of measurement) via gastrostomy tube (GTube, inserted through the belly that brings nutrition directly to the stomach) three times a day for anxiety ordered on 6/1/19 and Lexapro (a psychotropic medication) 5 mg every day for depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 28 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 significant impairment in daily life) ordered on 6/2/19. During a review of the clinical record for Resident 8, the Anxiety Disorder Care Plan intervention initiated on 7/9/19 indicated to monitor anxious complaints and provide reassurance by offering resident to go to wheelchair or go back to bed if mood seen. During review of the clinical record for Resident 8, the Depression Care Plan intervention initiated on 2/14/19 indicated to monitor verbalization of depression or sad facial expressions and encourage resident to verbalize feelings if mood seen. During an interview and record review with the director of nursing (DON) on 8/8/19 at 9:45 a.m., the DON confirmed there was no specific targeted behavior monitoring in Resident 8's medical records. 2. During a review of the clinical record for Resident 79, the Admission Records dated 8/8/19 at 12:10 p.m., indicated Resident 79 was admitted on 7/29/19 with diagnoses of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder. During a review of the clinical record for Resident 79, the Order Audit Report dated 8/8/19 at 12:21 p.m., indicated an order for Duloxetine (a psychotropic medication) HCI capsule delayed release particles 30 mg give 1 capsule by mouth every 12 hours for depression. During a review of the clinical record for Resident 79, the Depression care plan FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 29 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 intervention initiated on 6/14/19, indicated to monitor behavior of verbalization of depression and reassure resident of staff support and encourage participation in activities of choice if behavior seen. During an interview and record review with the DON on 8/8/19 at 10:23 a.m., the DON confirmed there was no specific targeted behavior monitoring in Resident 79's medical records. 3. During a review of the clinical record for Resident 116, the Admission Records dated 8/8/19 at 10:27 a.m., indicated Resident 116 was admitted on 7/12/19 with diagnoses of unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbance and muscle weakness. During a review of the clinical record for Resident 116, the Order Audit Report dated 8/8/19 at 12:23 p.m., indicated an order for Seroquel (an antipsychotic medication) tablets 25 mg give 1 tablet by mouth at bedtime for agitation ordered on 7/22/19. During a review of the clinical record for Resident 116, the Dementia care plan intervention initiated on 7/24/19 indicated to monitor behavior of physical aggression. During an interview with registered nurse M (RN M) on 8/7/19 at 11:45 a.m., RN M stated targeted behavior for Seroquel was when the resident shows behavior of wandering. During an interview with the DON on 8/7/19 at 12:21 p.m., the DON confirmed agitation was incorrectly indicated for Seroquel and needed to clarify with the MD. The DON also added facility staff were monitoring physical FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 30 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 aggression. During an interview and record review with the DON on 8/7/19 at 12:28 p.m., the DON confirmed there was no AIMS assessment done prior to starting Seroquel and also confirmed licensed nurses should be aware of the specific targeted behavior being monitored for a psychotropic medication. 4. Review of Resident 1's clinical record indicated he had the diagnosis of major depressive order (a mood disorder that causes persistent feelings of sadness and loss of interest). Review of Resident 1's physician's order, dated 7/25/19, indicated he was to receive Trazodone (antidepressant commonly used to treat sleeping difficulty) 50 mg by mouth at bedtime for insomnia (difficulty sleeping). Further review of Resident 1's clinical record indicated there was no documentation indicating staff were monitoring him for episodes of insomnia or for potential side effects from Trazodone from 7/25/19 onward. During an interview and concurrent record review with the minimum data set coordinator (MDSC) on 8/6/19 at 2:43 p.m., she stated residents taking Trazodone for insomnia must be monitored for potential side effects every shift. The MDSC explained these residents must also be monitored for the number of hours they sleep during the evening and night shifts. The MDSC reviewed Resident 1's clinical record and confirmed that from 7/25/19 onward, there was no documentation that staff had been monitoring his hours of sleep or for potential side effects from Trazodone. 5. Review of Resident 11's clinical record indicated she had diagnoses of malignant neoplasm (an abnormal growth that can grow FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 31 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 uncontrolled and spread to other parts of the body) and chronic pain syndrome. Review of Resident 11's physician order dated 7/28/19, indicated Lexapro 20 mg to give 1.5 tablet by mouth once daily for depression. Review of Resident 11's care plan for depression related to the disease process and use of Lexapro dated 7/31/19, indicated to monitor for signs of depression such as verbalization of depression and provide reassurance if mood seen. During an interview and record review with the DON on 8/8/19 at 4:52 p.m., she stated the monitoring for depression was as needed and it should have been monitored every shift. 6. Review of Resident 84's clinical record indicated he had diagnoses of bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) and hypertension (increase in blood pressure). Review of Resident 84's physician order dated 8/1/19, indicated to give Lithuim carbonate capsule by mouth every 12 hours for bipolar disorder. During interview and record review with the DON on 8/8/19 at 4:51 p.m., she stated the care plan behavior was calling out. The DON stated Resident 84's behavior monitoring was as needed and it should have been monitored every shift. Review of the facility's 8/2014 policy, "Psychoactive Medication Management", indicated "Medication side effects are monitored and documented on the medication administration record." The policy further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 32 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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, "Behavior monitoring is documented in the electronic health record (EHR) in the Point of Care (POC) module and If antipsychotic medication are used, an AIMS assessment will be completed upon admission, at the onset of a new order, and if medication dose is increased."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 09/07/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to label and store FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 33 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 medication in accordance with professional standards, including expiration dates, and storing medication at proper temperature according to manufacturer's recommendation. This failure could affect the integrity of the medications administered to the residents. Findings: During an inspection of the medication cart in Station 3 on 8/5/19 at 2:38 p.m. with licensed vocational nurse C (LVN C), an unopened eye drop medication (Latanoprost 0.005%, medication to treat high pressure inside the eye due to glaucoma, a group of eye conditions that can cause blindness) for Resident 69 was found inside the top drawer of the medication cart. During a concurrent interview with LVN C, she confirmed the findings. She stated the eye medication should be kept in the refrigerator until it is opened, according to manufacturer's recommendation. Once the medication is opened, it can be stored at room temperature. An inspection of the bottom drawer of the same medication cart were five Bisacodyl (a laxative to treat constipation) suppositories. There was no expiration date (predetermined date after which something should no longer be used) on the medications. During a concurrent interview with LVN C, she confirmed the findings. She stated medications should be labeled with the expiration date. Review of the facility's revised policy, dated 7/23/19, "Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles", indicated ... Facility should ensure that medications and biologicals have an expiration date on the label ... Facility should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 34 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 ensure that medications and biologicals are stored separately from infusion therapy products and supplies, under appropriate temperature and sterility conditions, according to the manufacturer's or supplier's recommendation.

F801 SS=D Qualified Dietary Staff CFR(s): 483.60(a)(1)(2)

F801 09/07/2019 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e) This includes: §483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose. (ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional. (iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 35 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section. (iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law. §483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who(i) For designations prior to November 28, 2016, meets the following requirements no later than 5 years after November 28, 2016, or no later than 1 year after November 28, 2016 for designations after November 28, 2016, is: (A) A certified dietary manager; or (B) A certified food service manager; or (C) Has similar national certification for food service management and safety from a national certifying body; or D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; and (ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and (iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the dietary staff had the competencies and skills to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 36 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 perform the job functions of the food and nutrition services, when the dietary staff was not aware of the dish machine temperature and sanitation process. This failure could affect proper washing and sanitation of dishes, glassware, and flatware, and could cause food borne illnesses to residents in the facility. Findings: During an observation and interview with the dietary aide (DA), on 8/5/19 at 10:20 a.m., she stated in Spanish, through the director of dietary service (DDS) as interpreter, the dishwasher's temperature was "200" degrees Fahrenheit (F, unit of temperature), then restated it was "100". The DDS confirmed the kitchen's dishwasher was a low temperature machine (machine that have wash and rinse cycles between 120-140 degrees F and does not achieve sanitation due to the temperature is not high enough. Low temperature dishwasher use chemical sanitizing agents (i.e. chlorine). When asked to demonstrate the sanitation process using the chlorine litmus strip (strip dipped into the sanitized water and result based on the color chart (between 50 -100 parts per million (ppm) to ensure the correct solution was created), the DA did not seem to know the process. The DDS asked for another DA to explain and show the sanitation process to this surveyor. During an interview with the RD on 8/6/19 at 2 p.m., she stated DA was hired as a dietary aide dishwasher. She stated they would retrain her again on dish washer and sanitation process. Review of DA's training/orientation checklist, dated 7/22/19, indicated she received training on the use of the dishwasher including checking temperature cycles during wash and rinse, and how to perform the litmus test for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 37 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 chlorine sanitation. Review of the facility's policy, dated 2/09, "Food and Dining Services, Training", indicated... All food and dining services personal will receive the appropriate orientation, education and training necessary to complete their assigned responsibilities...The Food and Dining Services Manager will ensure that each employee is familiar with all aspects of the proper completion of their specific duties as outlined in their job descriptions and timed duty assignments.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 09/07/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to ensure foods were FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 38 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 stored in accordance with professional standards for food service safety. This failure could potentially cause food-borne illnesses to residents in the facility. Findings: During the initial kitchen tour with the director of dietary services (DDS) on 8/5/19 at 7:49 a.m., the following were observed: 1. Six medium -sized clear plastic containers had strawberries with reddish black color at the bottom of the pack. 2. A box with a delivery date marked 7/30/19 had few potatoes with slight blackish color mixed in with fresh looking potatoes. 3. Icicles were hanging from the ventilation fans and on the upper walls of the walk-in freezer. The temperature reading was minus 10 degrees Fahrenheit. All of the observations above were confirmed by the director of dietary services (DSS). During a concurrent interview with the DDS, she stated all food items should be labeled with the expiration dates or use by date even though the delivery dates were marked on the food containers. She also stated she would have someone come and remove the icicles from the walk-in freezer. During further interview with the DDS, she stated it was her ultimate responsibility to check for the expiration dates and/or use-by dates. During a follow-up visit to the kitchen's walk-in freezer on 8/6/19 at 10:05 a.m. with the DSS and the registered dietitian (RD), the icicles were still present as observed during the initial kitchen tour. The temperature read minus 10 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 39 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 degrees Fahrenheit. Review of the facility's policy, "Food Safety in Receiving and Storage" dated 2/09, indicated ...Food is received and stored by methods to minimize contamination ...Expiration dates and use-by dates will be checked to assure the dates are within acceptable parameters.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 09/07/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 40 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to implement infection control practices for three of three residents (Residents 169, 172, and 320) when: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 41 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 1. For Residents 169, the licensed nurses did not use a barrier (i.e., tray, paper towel) for her flush syringe and alcohol wipes, prior to accessing a peripherally inserted central catheter (PICC line, a thin soft catheter inserted into the vein with the tip positioned into a large vein that carries blood to the heart; used for long-term IV antibiotics, nutrition or medications, or blood draws). 2. For Resident 172, laboratory technician did not don personal protective equipment (PPE, i.e. gown, glove, mask) prior to entering the residents' rooms, who were on contact precautions ( residents known or suspected to have serious illnesses transmitted by either direct or indirect contact). 3. For Resident 320, multiple staff did not don personal protective equipment prior to entering the residents' room. These failures had the potential to spread infections in the facility. Findings: 1. During a medication pass observation on 8/5/19 at 2:07 p.m., registered nurse A (RN A) administered intravenous(IV) antibiotic to Resident 169 via the PICC line. Prior to the IV antibiotic administration, RN A took a 10 milliliter (ml.,unit of liquid measure) Normal Saline (NS, a salt solution) syringe to flush the PICC line. RN A did not use a barrier (i.e a tray or paper towel) for the medication and syringe. She laid the NS syringe and the alcohol wipes on the bed next to Resident 169. During a concurrent interview with RN A, she confirmed the observation and acknowledged she should have used a barrier. She further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 42 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 she was taught to use a barrier during medication pass and administration. During an interview with the director of nursing (DON) on 8/6/19 at 3:50 p.m., she stated the licensed nurse should have used a barrier during their medication pass and administration. 2. Review of Resident 172's clinical record indicated she had diagnoses of methicillin resistant staphylococcus aureus (MRSA, bacteria causes infections in different parts of the body), hypertension (increase blood pressure), and muscle weakness. During an interview with RN A on 8/5/19 at 8:22 a.m., RN A stated Resident 172 had MRSA infection in the wound and on contact precaution. During an observation and interview with licensed vocational nurse N (LVN N) on 8/7/19 at 8:37 a.m., the laboratory technician went to Resident 172 and holding the resident hand with no gown. LVN N stated the laboratory technician should have wear a gown to prevent contamination related to MRSA. During an interview with the director of nursing (DON) on 8/7/19 at 5:15 p.m., the DON stated the laboratory technician should have wear gown during blood drawn for Resident 172. 3. Review of Resident 320's laboratory results dated 7/29/19 indicated she had clostridium difficile organism (a bacterium that can cause symptoms ranging from diarrhea to lifethreatening inflammation of the colon) present in the bowel. Review of Resident 320's care plan dated 7/30/19 indicated contact isolation to wear gloves, gown, and mask as needed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 43 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (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 observation on 8/5/19 at 8:35 a.m., certified nursing assistant G (CNA G) and CNA H entered Resident 320's room without wearing gloves and gowns. Both CNAs confirmed the observation. Both CNAs acknowledged they should have wore gloves and gowns before entering Resident 320 to prevent crosscontamination (when germs are unintentionally transferred from one object to another with harmful effects). During an another observation on 8/5/19 at 1:23 p.m., the physical therapist (PT) was observed inside the Resident 320's room and was not wearing gloves and gown. PT confirmed the observation. PT acknowledged he should have wear gloves and gown before entering Resident 320's room. During an interview with the director of staff development (DSD) on 8/5/19 at 8:56 a.m., she acknowledged CNA G and CNA H should have wore PPE before entering Resident 320's room. During an interview with the director of nursing (DON) 8/5/19 at 1:48 p.m., she stated the CNAs and PT should have wore PPE before entering Resident 320's room to prevent possible cross-contamination in the facility. Review of the facility's policy and procedures dated 2012, "Contact Precautions", indicated gloves and gown should be worn prior to entering the resident's room. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 44 of 45 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: _______________ 055645 (X3) DATE SURVEY COMPLETED 08/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE WIN POST-ACUTE 410 N Winchester Blvd Santa Clara, CA 95050 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F912 Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) SS=B ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 09/07/2019 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure multiple bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and service the residents receive. Findings: Room No. # Beds/Rm. Sq.Ft./Res. 301, 302, 303 2 71.5 304, 305, 309 2 71.5 311, 312, 314 2 71.5 During the survey, residents were observed in their rooms. Nursing care and services were not impacted by the shortage of space. The closets and storage were sufficient to accommodate the needs of the residents. During the survey, interviews were conducted to determine if there were any problems or issues with the lack of space or privacy. The residents and staff verbalized no complaints or concerns regarding space and privacy. Recommend the waiver remains in effect. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: V38E11 Facility ID: CA070000013 If continuation sheet 45 of 45