Health inspection·November 13, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document the status of residents' advance directives (AD, a written set of instructions, such as a living will or durable power of attorney for health care when the individual is incapacitated) for two of seven residents (Residents 20 and 34), when their clinical records lacked documentation for them. These failures had the potential for residents' wishes to not be fulfilled, should they become incapacitated. Findings: Resident 20 was admitted with diagnoses of TIA (Transient Ischemic Attack, a stroke that lasts a few minutes) and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Alzheimer's disease (a progressive diseases that destroys memory and other important mental functions), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), and dementia with agitation (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Review of Resident 20's physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form lacked indication whether an advanced directive was available, or not. The clinical record lacked an AD. During an interview with the Office Manager (OM) on [DATE] at 1:03 PM, she stated that she would usually discuss advanced directives as a subject with the family. The OM acknowledged it was not checked on the POLST form. Review of Resident 34's face sheet (a document that gives a resident's information at a glance) indicated she was admitted to facility on [DATE]. Resident 34 was admitted with diagnoses including alzheimer's disease, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and osteoarthrities (a disease that affects the joints and can cause pain and stiffness). Review of Resident 34's clinical record lacked an AD. Resident 34's POLST form, dated [DATE], had an AD section that was left blank (not completed). During an interview with minimum data set coordinator (MDSC) on [DATE] at 2:28 p.m., the MDSC confirmed the AD section D of the POLST forms were not completed for Resident 34 and should have been completed by staff. Page 1 of 10 555363 555363 11/13/2023 Lincoln Glen Skilled Nursing 2671 Plummer Avenue San Jose, CA 95125

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent record review for an AD for Resident 34 and interview with social service director (SSD) on [DATE] at 1:27 p.m., the SSD confirmed there was no AD for Resident 34. SSD stated the facility should have made attempts to obtain an AD for Resident 34. During an interview with director of nursing (DON) on [DATE] at 3:14 p.m., the DON confirmed there was no AD for Residents 34. The DON also confirmed the POLST form's section D for options for AD information was not completed for Residents 34. The DON stated the SSD should have made attempts to get an AD for Resident 34, and staff should have completed the POLST form without missing information for AD for Resident 34. Review of the facility's policy and procedure (P&P) titled, Advance Directives/Individual health Care Instructions, revised [DATE], the P&P indicated, Verifying and/or modifying the presence of advance directives or the resident's wishes with regard to CPR (cardiopulmonary resuscitation, help save a life when heart stops beating), upon admission; Periodically reviewing with the resident and resident representative the decisions made regarding treatments, experimental research and any advance directive and its provisions, as preferences any change over time . 555363 Page 2 of 10 555363 11/13/2023 Lincoln Glen Skilled Nursing 2671 Plummer Avenue San Jose, CA 95125

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment with comfortable sound levels, for one of fourteen sampled residents (Resident 201), when there were episodes of noise in the adjacent room of Resident 201 that was loud and bothersome to her. This failure had the potential to affect the sleep, comfort, and overall well-being of the resident. Findings: During a concurrent observation and interview of Resident 201 on 11/6/23 at 12:28 p.m., she was in her bed, eating her lunch. Resident 201 was alert, oriented, and verbally responsive. Resident 201 stated that the noise level in the next room can be loud, especially in the mornings when staff were getting carts and supplies. Review of Resident 201's face sheet (a document that gives a resident's information at a quick glance) indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stage 3 chronic kidney disease (CKD, mild to moderate gradual loss of kidney function), peripheral vascular disease (slow and progressive circulation disorder caused by narrowing of the blood vessel) and hyperlipidemia (high levels of fats in the blood). Her brief interview for mental status (BIMS, used to measure the resident's cognitive decline or improvements in a long-term care facility) score, done on 10/6/23, was 15 of 15 (intact cognition). During a concurrent observation and interview with registered nurse F (RN F) on 11/8/23 at 9:18 a.m., she verified that the housekeeping supplies room was adjacent to Resident 201's bed at the other side of the wall. RN F further verified that it could get noisy when the housekeepers were getting their supplies, especially in the morning. RN F stated that she has reminded the housekeepers to minimize their noise. During an interview with the assistant director of nursing/director of staff development (ADON/DSD), on 11/8/23 at 10:30 a.m., ADON/DSD verified that Resident 201 could hear loud noises from the adjacent room, since it was the housekeeping supplies room; that is, Resident 201's bed was beside the wall, adjacent to the housekeeping supplies room, especially when the housekeepers were busy getting their supplies and carts in the morning at the start of their shift. ADON/DSD stated that she has reminded the housekeepers to be mindful with the noise and to minimize it. ADON/DSD stated that she would remind the housekeepers again to be mindful with the noise and to minimize it when they were getting their supplies and carts, since Resident 201 could still hear the loud noise. ADON/DSD added that she would continue to remind the housekeepers to minimize the noise in the housekeeping supplies room. During an interview with housekeeper G (HK G) on 11/9/23 at 12:15 p.m., HK G verified that since the bed of Resident 201 was beside the housekeeping supplies room, it could get especially noisy in the morning, when they were getting the supplies and the carts. Review of the facility's policy and procedure titled, Noise Control, revised April 2014, indicated, The facility strives to maintain comfortable sound levels . Resident care and services should be 555363 Page 3 of 10 555363 11/13/2023 Lincoln Glen Skilled Nursing 2671 Plummer Avenue San Jose, CA 95125

F 0584 provided in a manner that promotes calm, organized and comfortable sound levels. Personnel should refrain from making loud noises . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555363 Page 4 of 10 555363 11/13/2023 Lincoln Glen Skilled Nursing 2671 Plummer Avenue San Jose, CA 95125

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to ensure the Office of the State Long-Term Care (a range of services and supports residents may need to meet their personal care needs for daily living) Ombudsman (advocates for residents in nursing home) was notified in writing when Resident 10 was transferred to the general acute care hospital (GACH). This failure had left the Long-Term Care Ombudsman unaware of of Resident 10's hospital transfer. Findings: Resident 10 was admitted to the facility with diagnoses which included Type 2 diabetes mellitus with diabetic chronic kidney disease, Stage 3 chronic kidney disease, retention of urine (a condition in which the resident is unable to empty all the urine from the bladder [a hollow shaped organ in human body that holds urine]), atherosclerosis (thickening or hardening of the arteries) of CABG (coronary artery bypass graft, is a surgical procedure used to treat coronary heart disease. It diverts blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply to the heart.), anemia (a condition in which the blood doesn't have enough healthy red blood cells), moderate protein-calorie malnutrition (lack of adequate nutrition), and abscess of liver (pus-filled pocket in the liver). Review of Resident 10's medical record lacked a notice of transfer to the hospital for Resident 10 to the Office of the State Long-Term Care Ombudsman. During an interview on 11/09/23 at 1:08 PM with the office manager (OM), she stated she could not find documentation that the Ombudsman was notified of Resident 10's transfer to the hospital or that such documentation was faxed to the ombudsman. Review of the facility's policy and procedure (P&P) titled, Transfer/Discharge Documentation, revised 9/5/22, it indicated, 1. Facility will: .d. Notify Long-Term Care Ombudsman of facility-initiated discharges or transfers. .12. Facility Initiated Transfer, Discharge, or Discharge while resident is still hospitalized : a. Provide notice to resident and resident representative, and Ombudsman Office at time the notice is provided to resident/resident representative at least thirty (30) days prior to the discharge/transfer or as soon as practicable. 555363 Page 5 of 10 555363 11/13/2023 Lincoln Glen Skilled Nursing 2671 Plummer Avenue San Jose, CA 95125

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure residents' environment remained free of accident hazards to prevent avoidable accidents, and provide safe environment for residents when: 1. Wheelchairs (a mobility aid device with wheels for use indoors and outdoors, intended for residents who are unable to walk and bear weight on their feet) were placed in-front of room A's bathroom door, which blocked it; and, 2. An antiskid mat was peeling off in room B's bathroom entrance. These failures had the potential for accidents that may result in injury to residents. Findings: 1. During an observation on 11/6/2023 at 10:30 a.m., two wheelchairs were placed in front of the bathroom door in room A. These two wheelchairs blocked the way to bathroom. There was a sign posted on bathroom door indicating, Please do not block door. During an interview with certified nursing assistant B on 11/6/2023 at 10:35 a.m., CNA B acknowledged two wheelchairs blocked Room A's bathroom door; and that, a sign posted on the bathroom's door indicated not to block it. CNA B stated when the bathroom door was blocked with wheelchairs, residents and staff were not able to enter the bathroom as needed, and was a risk for accidents. CNA B also stated staff should not have placed wheelchairs in front of the bathroom's door and followed a posted sign on the door for safety. CNA B removed both wheelchairs blocking Room A's bathroom after the interview. During an observation on 11/7/2023 at 9:11 a.m., one wheelchair blocked Room A's bathroom door. Signage posted on the bathroom door indicated to not block the door. During an interview with CNA C on 11/7/2023 at 9:13 a.m., CNA C confirmed one wheelchair blocked Room A's bathroom door, and a sign was posted on bathroom's door which indicated not to block the door. CNA C stated the bathroom door should not be blocked with objects for safety. CNA C also stated staff should not have placed the wheelchair in front of Room A's bathroom door to block it. During an interview with licensed vocational nurse D (LVN D) on 11/7/2023 at 9:20 a.m., LVN D confirmed there was a wheelchair placed in-front of Room A's bathroom door, and that there was a posted sign on bathroom door to not block the bathroom door. LVN D stated staff should not block the bathroom door with wheelchairs to prevent accidents. During an interview with assistant the director of nursing/director of staff development (ADON/DSD) on 11/7/2023 at 9:27 a.m., the ADON/DSD stated staff should not have blocked Rheum A's bathroom door with wheelchairs. The ADON/DSD stated staff should have followed the posted sign on Room A's bathroom's door to prevent risk of accidents, injury, and to provide a safe environment for residents in the facility. 2. During an observation on 11/6/2023 at 9:53 a.m., in room B, the antiskid mat on the bathroom 555363 Page 6 of 10 555363 11/13/2023 Lincoln Glen Skilled Nursing 2671 Plummer Avenue San Jose, CA 95125

F 0689 floor entrance was peeling off. Level of Harm - Minimal harm or potential for actual harm During a follow up observation on 11/7/23 at 8:39 a.m., the antiskid mat in room B's bathroom was still peeling off. Residents Affected - Few During a concurrent observation, and interview, on 11/07/23 at 9:17 a.m., with licensed vocational nurse A (LVN A) LVN A confirmed the above observations. LVN A stated that both residents in room B were at risk for falls and could use bathroom with supervision. LVN A further stated that she will report the loose antiskid mat to the maintenance because it was an accident hazard . During an interview with the assistant director of nursing/director of staff development (ADON/DSD) on 11/09/23 at 9:05 a.m., ADON /DSD stated that a peeling antiskid mat was an accident hazard that needed to be fixed to prevent injury. During a review of facility's policy and procedure (P&P) titled, Resident Rights, undated, the P&P indicated,Safe Environment. You have a right to a safe and clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. During a review of the facility's P&P titled, Falls Policy and Procedure, dated 6/19/15, the P&P indicated, The facility put approaches in place to prevent falls or injuries from falls. 555363 Page 7 of 10 555363 11/13/2023 Lincoln Glen Skilled Nursing 2671 Plummer Avenue San Jose, CA 95125

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview and record reviews the facility failed to follow their policy and procedure (P&P) by using bed side rails (SR: adjustable metal or rigid plastic bars that attached to the side of head of the bed) before attempting to use alternatives first for 14 of 14 residents (Residents 1, 8, 10, 19, 20, 24, 33, 34, 36, 38, 40, 48, 201, and 202). This failure had the potential to put the residents at risk for entrapment, serious injury and limiting their sense of independence. Findings: During the initial tour of the facility conducted on 11/6/2023 at 8:30 a.m., Residents 1, 8, 10, 19, 20, 24, 33, 34, 36, 38, 40, 48, 201, and 202, all had quarter SR elevated for their beds. Review of clinical records for Residents 1, 8, 10, 19, 20, 24, 33, 34, 36, 38, 40, 48, 201, and 202, lacked, documented evidence the facility attempted alternative approaches prior to using SR for beds. During an interview with license vocational nurse E (LVN E) on 11/8/2023 at 4:02 p.m., LVN E stated no alternatives for SR were tried before SR were used for residents' beds. During an interview with the assistant director of nursing/director of staff development (ADON/DSD) on 11/13/2023 at 11:29 a.m., the ADON/DSD acknowledged there were no alternative approaches attempted for SR before SR use was started for residents. The ADON/DSD stated the facility should have offered and attempted alternatives for SR prior to use of SR. During an interview with the director of nursing (DON) on 11/13/2023 at 12:05 p.m., the DON confirmed the facility did not attempt alternatives before use of SR for residents' beds. The DON stated staff should have offered and attempted to use of alternative approaches before using SR for residents per their policy for bed safety, and use of side rails. During a review of the facility's P&P titled, Bed Safety, revised December 2007, the P&P indicated, Side rails may be used if assessment and consultation with the attending physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. During a review of the facility's P&P titled, Proper Use of Side Rails, revised December 2016, the P&P indicated, Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 555363 Page 8 of 10 555363 11/13/2023 Lincoln Glen Skilled Nursing 2671 Plummer Avenue San Jose, CA 95125

F 0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate psychosocial services were provided for two of fourteen sampled residents, (Residents 40 and 1), when: Residents Affected - Few 1. For Resident 40, no psychosocial follow up was done after her altercation with Resident 1; and, 2. For Resident 1, no psychosocial follow up was done after her altercation with Resident 40 and a room transfer. These failures had the potential for the residents, not to attain or maintain the highest practicable physical, mental and psychosocial well-being. Findings: 1. During a concurrent observation and interview of Resident 40 on 11/6/23 at 9:05 a.m., Resident 40 was laying in her bed, alert and verbally responsive. Resident 40 stated that her roommate, Resident 1, tried to hit her yesterday but she was fine. Review of Resident 40's clinical records indicated, Resident 40 was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses including, stage 3 chronic kidney disease (CKD, mild to moderate gradual loss of kidney function), unspecified hyperlipidemia (high levels of fats in the blood) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Her brief interview for mental status (BIMS: used to measure the resident's cognitive decline or improvements in a long-term care facility) score was 8 (8-12: moderately impaired) meaning moderate cognitive impairment, done on 9/1/23. There was no psychosocial follow up done, for her altercation with Resident 1. During an interview with the social services director (SSD) on 11/9/23 at 10:20 a.m., SSD verified that she had not done a psychosocial follow up with Resident 40 after she had an altercation with Resident 1 since there was no physical contact between the residents. SSD further verified that she should have done a psychosocial follow up, even if there was no physical contact. During an interview with registered nurse F (RN F) on 11/9/23 at 11:11 a.m., RN F verified that the SSD should have done a psychosocial follow up of Resident 40 for her altercation with Resident 1. During an interview with assistant director of nursing/director of staff development (ADON/DSD) on 11/9/23 at 3:44 p.m., ADON/DSD verified that the SSD should have done a psychosocial follow up of Resident 40, even if Resident 40 was not hit or there was no injury during her altercation with Resident 1. 2. During a concurrent observation and interview of Resident 1 on 11/9/23 at 12:10 p.m., Resident 1 was in her new room, sitting in her wheelchair and having lunch. Resident 1 was confused and could not remember anything about her altercation with Resident 40 and her room transfer. Review of Resident 1's clinical records indicated, Resident 1 was a [AGE] year-old female, admitted to the facility on [DATE], with diagnoses including, chronic peripheral venous insufficiency (a 555363 Page 9 of 10 555363 11/13/2023 Lincoln Glen Skilled Nursing 2671 Plummer Avenue San Jose, CA 95125

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few condition in which veins have problems moving blood back to the heart) and polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body). Her BIMS score was 3 (0-7: severe impairment) meaning severe cognitive impairment, done on 9/20/23. There was no psychosocial follow up done, for her altercation with Resident 40 and for her room transfer. During an interview with the SSD on 11/9/23 at 10:15 a.m., she verified that she had not spoken to Resident 1 and had not done any psychosocial follow up with her after Resident 1's altercation with Resident 40 and after Resident 1's room transfer, because Resident 1 was confused. During an interview with RN F on 11/9/23 at 11:11 a.m., RN F verified that the SSD should have followed up on Resident 1 for her psychosocial status and condition after her altercation with Resident 40 and after Resident 1's room transfer. During an interview with the ADON/DSD on 11/9/23 at 3:50 p.m., the ADON/DSD verified that the SSD should have done a psychosocial follow up of Resident 1 for her altercation with Resident 40 and Resident 1's room transfer, even if she were confused. Review of the facility's policy and procedure (P&P) titled, Administrative Manual: Social Services, revised, 8/2/18, indicated, Facility will provide medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Social service task include, assistance in meeting the social and emotional needs of residents. Medically related social services include identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident and meeting the needs of residents who are coping with stressful events. 555363 Page 10 of 10