Inspection visit

Health inspectionOctober 7, 2022

Q: What happened during the October 7, 2022 survey of VISTA MANOR NURSING CENTER?

This was a inspection survey of VISTA MANOR NURSING CENTER on October 7, 2022. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Q: Were any deficiencies cited at VISTA MANOR NURSING CENTER on October 7, 2022?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered."

Q: What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

VISTA MANOR NURSING CENTERCMS #55548311 citations on this visit

11 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 328) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying then that Part A coverage is being terminated and providing information on how to file an appeal of that decision) letter in a timely manner. Residents Affected - Few This failure had the potential to prevent the resident from filing a timely appeal of the decision to discharge from Medicare Part A services. Findings: A review of Resident 328's clinical records indicated, Resident 328 was readmitted to the facility on [DATE] with diagnosis of pneumonia (infection of one or both lungs) with debility (physical weakness, especially because of illness). The facility initiated a discharge of Medicare Part A services on 9/14/2022 with benefit days remaining. A review of Resident 328's NOMNC letter indicated, The Effective Date Coverage of Your Current Skilled Nursing & Rehab Services Will End: 9-14-2022. Further review of the NOMNC letter's second page indicated, RP (responsible party - a person empowered to make decisions for the resident/ person legally responsible and liable for a decision or an action)) was notified via phone call on 9/15/22, also emailed her copy, dated 9/15/22. The NOMNC also indicated the RP's signature on 9/27/22. A review of the social service director's (SSD) progress note dated 9/15/2022 at 12:20 p.m., indicated, SSD called RP informed her resident was no longer receiving skilled services of 9-14-22 he will be transitioned to RNA (restorative nursing assistant - had special training and work alongside with rehab staff for patients with limited mobility and capacity of self-care) program explained to sister regarding NOMNC last covered days (LCD, days for skilled services) was 9-14-11, and LTC (long term care - services that include medical and non-medical care provided to people who are unable to perform basic activities of daily living such as dressing or bathing) as of 9-15-22. RP verbalized understanding of NOMNC. RP stated she was on vacation and to email her copy of NOMNC she will sign upon return. SSD emailed copy to RP on 9/15/22. During a concurrent interview and record review with SSD on 10/07/2022 at 10:02 a.m., the SSD reviewed Resident 328's NOMNC letter and progress note on 9/15/2022. The SSD confirmed she called Resident 328's sister who was the RP on 9/15/2022 to notify about the LCD of skilled services. The SSD stated the issuance and notification of the NOMNC letter's LCD should be done within 24 to 48 hours before the LCD for resident or RP to have time to appeal the decision. The SSD confirmed the (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 19 Event ID: 555483 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 notification of Resident 328's LCD to the RP was done the day after. Level of Harm - Minimal harm or potential for actual harm During a review of CMS (Centers for Medicare & Medicaid Services) Form Instructions 10123-NOMNC, titled Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS - 10123 indicated, The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily .A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 2 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of three employees was screened in accordance with their policies when there was no documentation that a background check was conducted prior to hire. This failure had the potential to compromise the safety and security of the residents. Residents Affected - Few Findings: Review of a faxed letter from the facility to the California Department of Public Health, dated 3/11/22, indicated certified nursing assistant J (CNA J) was accused of hitting and making fun of a resident. Review of CNA J's personnel file indicated she was hired by the facility on 9/6/11. There was no documentation that the facility conducted a background check before hiring CNA J. During an interview with the director of staff development (DSD) on 10/6/22 at 1:36 p.m., the DSD confirmed the facility must conduct background checks before hiring employees. The DSD stated she was not able to find documentation that the facility conducted a background check before hiring CNA J. The DSD further stated she reached out to the facility's corporate, who was also unable to find such documentation. Review of the facility's policy titled Abuse Prohibition and Prevention Program, revised 3/2018, indicated the facility does not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law. This includes attempting to obtain information from previous employers, current employers, and checking with the appropriate licensing boards and registries prior to hire and annually thereafter. Review of the facility's undated policy titled Background Screening Investigations indicated, The Personnel/Human Resources Director, or other designee, will conduct employment background checks, reference checks and criminal conviction checks (including fingerprinting as may be required by state law for RCFE) on persons making application for employment with this facility. The checks will be conducted in order to verify that the individual is qualified to work in the position that they are applying for in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 3 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 2. During observations on 10/3/22 at 11:03 a.m. and 3:15 p.m., Resident 24 was in her room receiving oxygen via nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen source). Residents Affected - Few Review of Resident 24's medical record indicated she had a physician's order, dated 8/2/22, for oxygen at 2 liters per minute (LPM, oxygen flow rate) via NC every shift. Further review of the medical record indicated Resident 24 did not have a care plan to address her use of oxygen. During an interview and concurrent record review with the director of nursing (DON) on 10/5/22 at 8:16 a.m., he confirmed that all interventions provided to the residents must be addressed on the care plan. The DON reviewed Resident 24's medical record and confirmed the facility did not develop a care plan to address her use of oxygen. 3. During observations on 10/3/22 at 10:40 a.m. and 3:15 p.m., Resident 175 was in her room receiving oxygen via NC. Review of Resident 175's medical record indicated she had a physician's order, dated 9/15/22, for oxygen at 2 LPM via NC every shift. She also had a physician's order, dated 9/22/22, for Mirtazapine (medication used to treat depression) 7.5 milligrams (mg, unit of dose measurement) 1 tablet by mouth at bedtime for depression manifested by poor appetite. Review of Resident 175's medication administration record (MAR) indicated she received Mirtazapine 7.5 mg 1 tablet by mouth at bedtime from 9/22/22 onward. Further review of the medical record indicated Resident 175 did not have care plans to address her use of oxygen and Mirtazapine. During an interview and concurrent record review with the DON on 10/5/22 at 8:16 a.m., he confirmed that all interventions provided to the residents must be addressed on the care plan. The DON reviewed Resident 175's medical record and confirmed the facility did not develop a care plan to address her use of oxygen. During a follow-up interview and concurrent record review with the DON on 10/5/22 at 12:58 p.m., he reviewed Resident 175's medical record and confirmed the facility did not develop a care plan to address her use of Mirtazapine. 4. Review of Resident 14's Physician Order, dated 4/6/2021, indicated, Eliquis (medication to prevent blood clot) 2.5 mg Give 1 tablet by mouth two times a day for deep vein thrombosis (DVT, when a blood clot forms in a deep vein.) Review of Resident 14's clinical records, there was no care plan addressing the use of Eliquis. During an interview and concurrent record review with the DON on 10/6/2022 at 4:00 p.m., DON confirmed there was no care plan addressing the use of Eliquis and acknowledged there should have been a care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 4 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's policy titled Care Plan Goals and Objectives, dated 7/1/2020 indicated, the goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved. Based on observation, interview and record review, the facility failed to develop care plans for four of 18 sampled residents (Residents 18, 24, 175 and 14). 1. For Resident 18, the facility did not develop a care plan to address the use of insulin; 2. For Resident 24, the facility did not develop a care plan to address the use of oxygen; 3. For Resident 175, the facility did not develop care plans to address the use of oxygen and antidepressant medication; and 4. For Resident 14, the facility did not develop a care plan to address the use of anticoagulant (blood thinner). This failure had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. A review of Resident 18's clinical record indicated Resident 18 had a physician's orders dated 7/27/2022 for a routine Humalog (insulin - a hormone used to lower the blood sugar) three times a day and a Humalog sliding scale (varies the dose of insulin based on blood sugar level) before meals and at bedtime for diabetes mellitus (DM - a condition which affects the way the body processes blood sugar). Further review of Resident 18's physician's order indicated an order dated 08/23/2022 of Lantus (type of insulin to lower the sugar in the blood) to be given once a day and at bedtime for DM. During a concurrent interview and record review with the minimum data set nurse (MDSN - a nurse responsible for a resident's scheduled assessment and care planning) on 10/06/2022 at 1:44 p.m., the MDSN reviewed Resident 18's list of care plans. The MDSN confirmed there was no care plan developed for insulin use. The MDSN stated there should have been a care plan developed for Resident 18's insulin use. During a review of the facility's policy and procedure titled, Care Plan Goals and Objectives, dated 07/01/2020, indicated, It was the policy of this facility that care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 5 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to adhere to appropriate professional standard of care for one of two sampled residents (Resident 58) when a licensed nurse forcefully introduces through a gastric-tube (g-tube inserted through the belly) the medication causing leakage. Residents Affected - Few This failure had the potential for residents not to received complete dose of medication. Findings: During an observation on 10/3/22, at 4:56 p.m., in Resident 58's room, Licensed Vocational Nurse A (LVN A) administered medication forcefully via g-tube causing it to leak on Resident 58's abdomen. During interview on 10/3/22, at 5:06 p.m., outside Resident 58's room, LVN A stated that she should have not exerted pressure in giving medication thru g-tube. During an interview on 10/04/22, at 1:30 p.m., with Director of Nursing (DON), he stated, medication thru g-tube should be administered by gravity unless there was a prescriber's order to push. During a review of facility's policy titled Administering Medication Through an Enteral Tube, dated 7/01/2020, indicated, the purpose of this procedure was to provide guidelines for the safe administration of medications through an enteral tube. Administer medication by gravity flow. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 6 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 follow the physician's order to apply compression stockings (elastic stockings apply to the legs) to one of 18 sampled residents (Resident 21) related to edema (swelling) of both lower extremity. This failure had the potential to affect the residents physical and mental well being in the facility. Residents Affected - Few Findings: Review of Resident 21's clinical record, Resident 21 was admitted on [DATE], with diagnoses of Hypertensive Heart Disease with Heart Failure (heart condition caused by heart caused by high blood pressure), Heart Failure (the heart muscle is unable to pump enough blood to meet the body's needs). Review of Resident 21's Physician Order, order date 8/13/2021, indicated, Compression stockings to both lower extremity (BLE) one time a day for edema. Apply stockings at 6:30 a.m. Remove stockings at bedtime. Review of Resident 21's Nursing Weekly Observations, dated 10/1/2022, indicated, Edema: 1 plus (a grading system used to determine the severity of the edema) and pitting on both lower extremities. During an observation on 10/4/2022, at 10:54 a.m., while at Resident 21's room. Resident 21 was sitting in her wheelchair and Family Member 1 (FM 1) was standing next to the resident. Facility staff was applying the compression stockings to both of Resident 21's lower legs. Resident 21 was observed with swelling on both legs. During a concurrent interview with FM1, she stated Resident 21 was supposed to have the compression stockings put on in the morning, but that it doesn't always happen. FM 1 stated she was not informed of any episodes of refusal from Resident 21. During an interview with Certified Nursing Assistant L (CNA L) on 10/4/2022, at 1:34 p.m., CNA L stated Resident 21's compression stockings was not applied this morning. CNA L stated we sometimes apply the compression stockings on different times, CNA L further stated it should be applied in the morning before getting out of bed. During an observation and concurrent interview with Licensed Vocational Nurse M (LVN M) on 10/4/2022, at 1:37 p.m., while at Resident 21's room. LVN M stated Resident 21's compression stockings should be applied in the morning. LVN M stated they removed the compression stockings applied earlier and changed it to a bigger size because Resident 21 verbalized it was too tight. Surveyor observed facility staff putting on a new pair of compression stockings to Resident 21. During an interview and concurrent record review with the Director of Nursing (DON) on 10/6/2022, at 4:00 p.m., DON confirmed Resident 21's physician's order related to applying compression stockings in the morning. DON stated he expects facility staff to follow physician's order unless residents refuse. Upon further review of records, DON confirmed there was no record of refusal from Resident 21. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 7 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to store medications in a safe and effective manner when expired medications were found in two of two medication rooms. This failure could result to unsafe medication administration to residents. Findings: During a concurrent observation and interview with nurse supervisor F (NS F) on 10/3/22 at 11:32 a.m , in medication room A, a bottle of acidophilus (probiotic) with an expiration date of 7/2022., was found inside the medication refrigerator. A vial of lorazepam (a medication to treat anxiety) with an expiration date of 9/2022 was also found in the emergency kit. NS F stated it should have been thrown away and have discarded per their policy. During a concurrent observation and interview with NS F on 10/3/22 at 11:41 a.m , in medication room B, two bottles of Resident 58's lansoprazole (a medication to treat prevent and treat stomach ulcer) were found in the medication refrigerator. The first bottle had an expiration date of 9/22/22, and the other bottle was 10/2/22. NS F stated it should have been thrown away and discard per policy. During an interview with director of nursing (DON) on 10/4/22, at 1:41 p.m., expired medications should have been discarded. During a phone interview, on 10/5/22 at 2:26 p.m., with the facility's consultant pharmacist (CP), she stated expired medications should have been discarded. CP further stated that the facility should notify the pharmacy if medication in emergency kit was expired Review of facility's Storage of Medications policy, dated 7/1/2020, indicated that the facility ensure all drugs are stored in a safe , secure , and orderly manner. It further indicated that the facility shall not use discontinued , outdated, or deteriorated drugs' or biological . All such drugs shall be returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 8 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of 18 sampled residents (Residents 175 and 69) were free from unnecessary psychotropic medications (medications that cause changes in mood, feelings or behavior) when: 1. For Resident 175, licensed nurses did not monitor for side effects and target behaviors (behaviors intended to be changed or eliminated by the psychotropic medication); and 2. For Resident 69, licensed nurses did not consistently monitor for side effects and target behaviors, and did not complete an abnormal involuntary movement scale assessment (AIMS assessment, a tool used to monitor for abnormal bodily movements caused by antipsychotic medication). These failures had the potential to compromise the residents' health and well-being. Findings: 1. Review of Resident 175's medical record indicated she was admitted on [DATE] and had the diagnosis of unspecified dementia (mental disorder caused by brain disease or injury) with behavioral disturbance. Review of Resident 175's Order Summary Report indicated she had a physician's order, dated 9/22/22, for Mirtazapine (medication used to treat depression) 7.5 milligrams (mg, unit of dose measurement) 1 tablet by mouth at bedtime for depression manifested by poor appetite. Review of Resident 175's medication administration record (MAR) indicated Resident 175 received Mirtazapine 7.5 mg at bedtime from 9/22/22 onward. There was no documentation of side effects or target behavior monitoring for Mirtazapine. During an interview and concurrent record review with the director of nursing (DON) on 10/5/22 at 12:58 p.m., he stated for residents taking psychotropic medications, licensed nurses should monitor for side effects and target behaviors every shift and document this on the MAR. The DON stated it was important to monitor side effects and target behaviors to determine if the psychotropic medication doses needed to be adjusted, and to determine whether or not the medications were effective. The DON reviewed Resident 175's medical record and confirmed there was no documentation of side effects or target behavior monitoring for Mirtazapine. 2. Review of Resident 69's medical record indicated she was admitted on [DATE] and had the diagnosis of dementia with behavioral disturbance. Review of Resident 69's Clinical Physician Orders indicated she had orders, dated 9/7/22, for the following medications: 1) Olanzapine (medication used to treat psychosis) 20 mg 1 tablet by mouth at bedtime for psychosis manifested by talking to self; 2) Paroxetine (medication used to treat depression) 30 mg 1 tablet by mouth at bedtime for depression manifested by loss of interest to previous enjoyable activities; and 3) Lorazepam (medication used to treat anxiety) 1 mg 1 tablet by mouth three times a day for anxiety manifested by inability to relax as evidenced by hand fidgeting. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 9 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Review of Resident 69's MAR, dated 9/2022 and 10/2022, indicated licensed nurses were to monitor side effects and target behaviors for the above psychotropic medications every shift. From 9/7/22 to 10/4/22, there were ten (10) shifts for which there was no documentation of side effects monitoring, and nine (9) shifts for which there was no documentation of target behavior monitoring for all three of the above psychotropic medications. Residents Affected - Few Further review of Resident 69's medical record indicated there was no documentation of an AIMS assessment upon admission. During an interview and concurrent record review with the director of nursing (DON) on 10/5/22 at 12:58 p.m., he stated for residents taking psychotropic medications, licensed nurses should monitor for side effects and target behaviors every shift and document this on the MAR. The DON stated for residents taking antipsychotic medications (such as Olanzapine), licensed nurses should complete an AIMS assessment upon admission and quarterly thereafter. The DON reviewed Resident 69's medical record and acknowledged there were several shifts with no documentation of side effects and target behavior monitoring. The DON confirmed the facility did not complete an AIMS assessment for Resident 69. Review of the facility's policy titled Psychotropic Medication Use, revised 3/2015 indicated, The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including psychotropic medications. Nursing staff shall monitor for and report .side effects and adverse consequences of psychotropic medications to the Attending Physician. Review of the facility's policy titled Behavior Assessment and Monitoring, revised 4/2007, indicated staff will document the number and frequency of specific problem behaviors. The policy also indicated the nursing staff and physician will monitor for side effects and complications related to psychoactive medications. Review of the facility's undated document titled Assessing Abnormal Involuntary Movement During Antipsychotic Therapy indicated to do an AIMS assessment prior to initiating antipsychotic therapy and every 6 months thereafter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 10 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a 17.6% medication error rate when five medication errors out of 28 opportunities were observed during medication administration for four residents (Resident 2,50,63, and 122). This failure had the potential to compromise the resident's medical health. Residents Affected - Some Findings: 1. During a concurrent observation and interview on 10/3/22 at 9:27 am, licensed vocational nurse C (LVN C) administered the scheduled morning medications to Resident 2 except metoprolol (blood pressure medication). LVN C stated metoprolol was not available. Resident 2's blood pressure reading was 128/80 mm Hg, the systolic blood pressure(SBP) was 128. Review of Resident 2's physician order, dated 9/12/22, indicated to administer metoprolol 25 milligrams (mg, unit of measurement) 1 tablet two times a day for hypertension and hold if SBP was <110, HR<60. During an interview on 10/3/22 at 2:40 p.m., LVN C stated she missed giving the metoprolol as it was not available. Review of facility's policy, titled Administering Medications, dated 7/1/2020, indicated that medications should be administered in a safe and timely manner as prescribed by the healthcare provider 2. During an observation on 10/3/22 at 9:55 am, LVN E administered the scheduled morning medications to Resident 50 including Trospium Chloride (urinary spasmosdics) , 20 mg tablet. Review of Resident 50's physician orders, dated 4/16/2021, indicated to administer Trospium Chloride 20 mg 1 tablet two times a day for overactive bladder; at 9 a.m. and 5 p.m. During a concurrent interview and record review, on 10/03/22 at 2:54 p.m. with LVN E, she stated that there was no special instruction on the Resident 50' physician order, however, there was a pharmacy note to administer it on an empty stomach.The pharmacy note was posted on Resident 50's medication bubble pack. LVN E stated she gave it on a full stomach. Review of facility's Drug Handbook 2020, indicated to administer trospium at least 1 hour before meals or on an empty stomach. During an interview with the director of nursing (DON) on 10/5/22 at 3:20 p.m., DON stated trospium should be administered 30 minutes to 1 hour before meals. During a phone interview with the facility's consultant pharmacist (CP), on 10/5/22 at 2:26 p.m. ,she stated trospium should be administered in an empty stomach. 3. During an observation on 10/3/22 at 4:01p.m, LVN A administered Humalog (rapid acting insulin) 3 units subcutaneously on Resident 63's right arm. Dinner was not served as of 5:15 pm. During an interview on 10/3/22 at 5:06p.m., LVN A , she stated Humalog should be give 10-15 minutes before meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 11 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 63's physician order, dated 10/22/21, indicated to administer Humalog 3 units subcutaneously for blood sugar between 201-250; before meals and at bedtime for diabetes. Review of facility's Drug Handbook 2020 indicated to administer Humalog immediately before meals. During an interview with the director of nursing (DON) on 10/4/22 at 1:28 p.m., DON stated humalog should be administered 30 minutes before meals. During a phone interview with the facility's CP, on 10/5/22 at 2:26 p.m.,she stated short acting and rapid acting insulin should be administered 15 minutes before meals or immediately after meals. 4. During an observation on 10/3/22 at 4:24 p.m., LVN B administered humulin R (short acting insulin) 5 units and admelog 2 units (rapid acting insulin ) subcutaneously to Resident 122's right arm at 4:25 p.m. Dinner was not served as of 5:15 pm. Review of Resident 122's physician orders, dated 9/17/22, indicated to administer admelog 2 units before meals and at bedtime for diabetes. Review of Resident 122's physician orders, dated 9/18/22, indicated to administer humulin R (short acting insulin) 5 units before meals and at bedtime for diabetes. Review of facility's Drug Handbook 2020 indicated to administer Humulin R and admelog 30 minutes before meals. During an interview with the director of nursing (DON) on 10/4/22 at 1:28p.m., DON stated humalog should be administered 30 minutes before meals. During a phone interview with the facility's CP, on 10/5/22 at 2:26 p.m.,she stated short acting and rapid acting insulin should be administered 15 minutes before meals or immediately after meals. Review of facility's Insulin Administration policy, dated 7/1/2020 indicates licensed staff should follow the guidelines for the safe administration of insulin to residents with diabetes Review of facility's policy, titled Administering Medications, dated 7/1/2020 indicated that medications should be administered in a safe and timely manner as prescribed by the healthcare provider FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 12 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food was stored and labeled in accordance with professional standards for food safety when: Residents Affected - Some 1. Two refrigerators did not have internal thermometers and; 2. A bag of food inside of the resident's refrigerator did not have a label, These failures had the potential to cause the growth of microorganisms and foodborne illness for the 64 residents eating at the facility. Findings: 1. During a concurrent observation and interview with the Registered Dietitian (RD) on 10/3/2022 at 11:49 a.m., in the kitchen, there was no thermometer inside the Refrigerator 1. The RD stated they should have a thermometer inside the refrigerator. During a concurrent observation and interview with the Dietary Supervisor (DS) on 10/3/2022 at 11:58 a.m., in the kitchen, there was no thermometer inside Refrigerator 2. The DS stated they should have a thermometer inside the refrigerator. During an interview with the Director of Nursing (DON) on 10/6/2022 at 11:35 a.m., the DON stated a thermometer should be inside each refrigerator. The DON further stated without the thermometer, the refrigerator temperature would not be properly monitored. The DON stated these would possibly affect the quality of the food and would cause foodborne illness. During an interview with the RD on 10/6/2022 at 1:29 p.m., the RD stated they should have an internal thermometer to monitor the temperature. The RD further stated the food were not safe to serve if they turned warm. A review of the facility's policy and procedure titled Food Storage, dated 2017, indicated every refrigerator must be equipped with an internal thermometer. 2. During a concurrent observation and interview with Licensed Vocational Nurse G (LVN G) on 10/5/2022 at 3:35 p.m., a bag of food without resident's name, room number, and date was observed in the residents' refrigerator. The LVN G stated they should have labeled the food brought from home with resident's name, room number, and date. The LVN G further stated resident's food should be kept for 24 hours. During an interview with the DON on 10/6/2022 at 11:35 a.m., the DON stated resident's food brought by the family should be stored in the refrigerator and should be labeled with name, room number, and date. A review of the facility's Policy and Procedure (P&P) titled Use and Storage of Food Brought to Resident, dated 10/26/2020, indicated that perishable food must be stored in the refrigerator in re-sealable containers with tightly fitting lids. Containers will be labeled with the resident's name, date initially covered, and the manufacturer use by date, as applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 13 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 4a. During an observation on 10/3/22 at 10:52 a.m., Resident 12 was in her room receiving oxygen via NC. The oxygen tubing was not labeled and dated. Residents Affected - Some During an observation and concurrent interview with NS F on 10/3/22 at 3:15 p.m., Resident 12 was in her room receiving oxygen via NC. NS F looked at Resident 12's oxygen tubing and confirmed it was not labeled and dated. NS F stated licensed nurses were supposed to change oxygen tubing every week and label the tubing with the date it was changed. Review of Resident 12's medical record indicated there was no documentation indicating when her oxygen tubing was last changed. During an interview and concurrent record review with the director of nursing (DON) on 10/7/22 at 11:00 a.m., he reviewed Resident 12's medical record and confirmed there was no documentation indicating when her oxygen tubing was last changed. The DON acknowledged that since Resident 12's oxygen tubing was undated, there was no way to tell when it was last changed. Review of the facility's undated policy titled Oxygen Administration indicated, Oxygen tubing and humidifier will be changed every 7 days and as needed. 4b. During an observation on 10/3/22 at 11:03 a.m., Resident 24 was in her room receiving oxygen via NC. The oxygen tubing was not labeled and dated. During an observation and concurrent interview with NS F on 10/3/22 at 3:15 p.m., Resident 24 was in her room receiving oxygen via NC. NS F looked at Resident 24's oxygen tubing and confirmed it was not labeled and dated. NS F stated licensed nurses were supposed to change oxygen tubing every week and label the tubing with the date it was changed. Review of Resident 24's medical record indicated she had a physician's order, dated 8/2/22 for, Tubing Change Nasal Cannula/Tubing & Storage Bag every week. Date Tubing and Bag. Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Staff did not wear N95 masks (a high filtering facepiece device designed to achieve a very close facial fit that filter at least 95% of airborne particles) properly; 2. Certified nursing assistant I (CNA I) did not disinfect the vital signs machine (blood pressure machine, pulse oximeter, thermometer in one machine attached to a pole with tray and wheels) after use; 3. Resident 35's oxygen tubing was not dated and labeled; 4. Licensed nurses did not label and date the oxygen tubing for Residents 12 and 24; 5. Staff did not perform hand hygiene during medication pass; 6. Staff did not disinfect the insulin vial rubber top; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 14 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 7. Resident 7' oxygen tubing was not dated and labeled and nebulizer (breathing treatment machine) mask was not stored properly; 8. The director of nursing (DON) did not properly wear the N95 mask at the nurse station; 9. The certified nurse assistant K (CNA K) did not go through the COVID-19 (a highly contagious viral infection) screening (consists of a verbal symptom questionnaire and temperature check) assessment prior to entrance to the facility and; 10. Resident 322's oxygen concentrator's filter was not cleaned. These failures had the potential to result in transmission of infection in the facility that could affect 66 out of 66 residents. Findings: 1a. During an observation on 10/3/22 at 8:00 a.m., in the facility's main entrance, the facility receptionist (FR) was wearing an N95 incorrectly. The two straps of the N95 mask were observed behind each ear of the FR. The straps were not observed on the crown (topmost part of the head) or behind the neck of the FR. During additional observation on 10/3/22 at 8:34 a.m., near the facility's entrance, the two straps of the FR's N95 were observed behind each ear. The FR confirmed the observation and stated she did cut the straps of the N95. 1b. During an observation on 10/3/22 at 8:44 a.m., in the hallway near the resident's room, licensed vocational nurse H (LVN H) was wearing an N95 incorrectly. The two straps of the N95 mask were observed behind each ear of LVN H. There were no straps observed on the crown or behind LVN H's neck. During a concurrent interview with LVN H, she confirmed the above observation. During an interview with the infection preventionist (IP) on 10/6/22 at 4:22 p.m., the IP stated she had observed staff wearing N95 incorrectly. The IP further stated it was not ok for staff to wear N95 without the strap resting at the back of the head because it would not fit. According to the CDC's website (https://www.cdc.gov/niosh/docs/2010-133/pdfs/2010-133.pdf How to Properly Put on and Take Off a Disposable Respirator indicated the top strap goes over and rests at the top back of your head. The bottom strap is positioned around your neck and below the ears. 2. During an observation on 10/4/22 at 8:23 a.m., certified nursing assistant I (CNA I) took Resident 32's vital signs (clinical measures of pulse rate, temperature, respiratory rate, blood pressure). During an observation on 10/4/22 at 8:28 CNA I went out from the room without disinfecting the medical equipment then proceeded to the nursing station and plug in the equipment. During an interview and concurrent observation with CNA I on 10/4/22 at 8:29 a.m., CNA I confirmed she took Resident 32's vital signs and acknowledged she did not disinfect the machine after use. CNA I further stated she should use a sanitizer wipe in the station. CNA I then look at the cabinets in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 15 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 the station and confirmed there was no sanitizer wipes. Level of Harm - Minimal harm or potential for actual harm During an interview with the IP on 10/6/22 at 4:22 p.m., the IP stated staff should sanitize the vital signs machine after each resident use. Residents Affected - Some Review of the facility's undated policy, Non-Critical Items-Cleaning & Disinfection indicated, Non-critical items that come in contact with intact skin but no mucous membranes and that have not become soiled will be cleaned periodically. 3. During an observation on 10/3/22 at 10:42 a.m., in Resident 35's room, Resident 35 was lying in bed with oxygen on at 2 liters per minute (LPM, flow of oxygen) via nasal cannula (NC, a device used to deliver supplemental oxygen to a person). The oxygen tubing was not dated and labeled when the last time it was changed. There was an oxygen tank at the foot of the bed with unlabeled oxygen tubing and it was not in bag. During a concurrent observation and interview with nurse supervisor F (NS F) on 10/3/22 at 3:21 p.m., in Resident 35's room, NS F confirmed Resident 35's oxygen tubing's were not labeled. NS F further stated all oxygen tubing at the bedside should be all labeled. Review of Resident 35's physician order dated 10/25/21 indicated Tubing-Change Nasal Cannula/Tubing & Storage Bag every week. Date Tubing and Bag. 7. Review of Resident 7's Physician Order, dated 5/6/2021, indicated, Oxygen at 2-3 liters/min via nasal cannula every shift. Change nasal cannula tubing/tubing and storage bag every week. Date tubing and bag. Review of Resident 7's Physician Order, dated 11/1/2017, indicated, Albuterol Sulfate Nebulization Solution (a breathing treatment solution), 1 vial to be administered every 6 hours as needed for shortness of breath. During an observation on 10/3/2022 at 12:28 p.m., while at Resident 7's room. Resident 7 was lying in bed and receiving oxygen at two LPM via nasal cannula (NC, a device used to deliver supplemental oxygen), oxygen tubing was not labeled. There was also a nebulizer mask sitting on top of the drawer next to the bed without a protective covering. During an interview with the Licensed Vocational Nurse E (LVN E), on 10/3/2022 at 3:31 p.m., LVN E confirmed the above observation, and stated the nasal cannula should be labeled with Resident 7's name, room number, and date of when it was changed. LVN E further stated the nebulizer mask should be kept inside a plastic bag when not in use. Review of facility's policy and procedure, Administering Medications through a Small Volume Nebulizer, dated 7/1/2020, indicated, When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. 8. During an observation on 10/05/2022 at 11:22 a.m., the DON was observed wearing N95 mask at the nurse station where the upper loop was placed on top of the N95 mask. Another observation on 10/05/2022 at 4:32 p.m., the DON was observed sitting at the nurse station with his N95 mask resting on his chin while talking to a visitor in front of the nurse station. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 16 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with the infection preventionist (IP) on 10/06/2022 at 4:30 p.m., the IP confirmed the N95 mask should be worn properly, wherein the upper loop should be behind the top part of the head and the lower loop should be at the back of the neck. The IP further stated the mask should not be pulled down while talking to somebody. During an interview with the DON on 10/07/2022 at 11:15 a.m., the DON confirmed N95 mask should be worn properly especially at the nurse station with other staff and visitors. 9. During a concurrent observation and interview on 10/05/2022 at 3:00 p.m., the CNA K entered the facility thru the back door, passed by the hallway and nurse station to clocked in. The CNA K stated, I should have entered the front entrance to get screened. During an interview with the IP on 10/06/2022 at 4:27 p.m., the IP stated all staff should enter the front door to get screened for COVID-19 symptoms. The IP further stated COVID-19 screening should be done prior to entry to determine if staff are sick before working with residents. During an interview with the DON on 10/07/2022 at 11:15 a.m., the DON stated staff should enter at the front desk to get screened prior to entry to the facility. A review of the Centers for Disease Control and Prevention (CDC) Infection Control Guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19 Pandemic, updated September 23, 2022, indicated, 1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a process to make everyone entering the facility aware of recommended actions to prevent transmission to others if they have any of the following three criteria: 1) a positive viral test for SARS-CoV-2; 2) symptoms of COVID-19, or 3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure (for healthcare personnel - HCP). 10. During an observation on 10/03/2022 at 10:35 a.m., inside Resident 322's room, Resident 322 was sitting at the edge of bed on continuous oxygen using a nasal cannula. The oxygen concentrator's filter (black foam that catches dirt or dust) located at the back had a buildup of grayish substance. During an interview with the nurse supervisor F (NS F) on 10/03/2022 at 3:16 p.m., the NS F stated the maintenance were in charged of cleaning the oxygen concentrator once a resident was discharged from the facility. The NS F further stated maintenance staff should clean the oxygen filter, if needed. During a follow-up observation and interview with the NS F on 10/04/2022 at 11:29 a.m., inside Resident 322's room, the NS F confirmed the oxygen filter looks dusty. The NS F stated the oxygen filter should be cleaned. During another follow-up observation and interview with the IP on 10/05/2022 at 3:49 p.m., inside Resident 322's room, the IP confirmed the oxygen filter was not clean. The IP stated the maintenance and central supply staff should be checking the filter daily. Review of the oxygen concentrator's manufacturer's instructions, titled 7.3 Cleaning the Cabinet Filter, indicated, DO NOT operate the concentrator without the filter installed or with a dirty filter. Remove the filter and clean as needed. Environmental conditions that may require more frequent inspection and cleaning of the filter include, but are not limited to: high dust, air pollutants, etc. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 17 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. During an observation on 10/3/2022 at 9:26 a.m., in Resident 2's room, Licensed Vocational Nurse (LVN C) prepared the medications without doing hand hygiene after checking the Resident 2's blood pressure. At 9:31 a.m., she changed gloves with no hand hygiene after touching the trash can. During an interview with LVN C on 10/3/2022 at 9: 52 a.m. she stated she should do hand hygiene before and after medication preparation. During an interview with the Director of Nursing, on 10/4/2022, at 1:26 p.m., he stated the nurses should follow the Handwashing or Hand hygiene policy during medication passes and after removing and changing gloves. During a review of facility's policy Title: Handwashing /Hand Hygiene indicated use an alcohol -based hand rub containing at least 62 percent alcohol; or, alternatively soap (antimicrobial or non-antimicrobial) and water for the following situation: Before preparing or handling medications; before donning sterile gloves; and after removing gloves. 6. During an observation on 10/3/2022, at 12:00 p.m., Registered Nurse (RN D) was preparing Admelog Solostar Solution (insulin) pen -injector. RN D inserted the needle on top of the vial without cleaning the top of the vial. During interview on 10/3/2022, at 12:04 p.m., RN D stated she should have wiped the rubber seal with an alcohol wipe before inserting the needle. During an interview on 10/04/202, at 1:28 p.m., with Director of Nursing (DON), he stated that licensed nurses should disinfect the insulin vial with a clean alcohol wipe. Review of facility's Insulin Administration policy, dated 7/1/2020, indicated licensed staff should follow the guidelines for the safe administration of insulin to residents with diabetes. It further indicated to disinfect the top of the insulin vial with an alcohol wipe. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 18 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/07/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Manor Nursing Center 120 Jose Figueres Avenue San Jose, CA 95116 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a safe environment for staff and residents when staff used paper towels to light the pilot light in the oven. These failures had the potential to cause staff injuries and a fire hazard for 66 residents in the facility. Findings: During an observation on 10/3/2022 at 11:22 a.m., in the kitchen, the cook (a person who prepares and cooks food as a job or in a specified way) lit the paper towels three times from the stove top and tried to start the oven's pilot light at the bottom of the oven multiple times. During an interview with the Registered Dietitian (RD) on 10/3/200 at 11:41 a.m., The RD stated that staff should not use paper towels to light the oven's pilot light. The RD further stated lighting up a pilot light using the paper towel was not a safe practice. During an interview with the cook on 10/4/2022 at 9:20 a.m., the cook stated it was wrong to use the paper towel to light the oven's pilot light, and he should not have done that. During an interview with the Director of Nursing (DON) on 10/7/2022 at 11:00 a.m., the DON stated they were not supposed to use paper towels to light the oven's pilot light. The DON further stated it might injure the staff and might cause a fire hazard. A review of the undated manufacturing instruction titled Standard Oven Lighting and Shutdown instructions indicated, . remove the lower panel, depress the red button on the safety valve and light the pilot, hold down the red button for at least 30 seconds, when the button is released, the pilot should remain it .if the pilot becomes extinguished, repeat the above procedure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555483 If continuation sheet Page 19 of 19

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Citations

11 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0582GeneralS&S Dpotential for harm
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
0607GeneralS&S Dpotential for harm
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0658GeneralS&S Dpotential for harm
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0921GeneralS&S Dpotential for harm
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
0759GeneralS&S Epotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.

FAQ · About this visit

Common questions about this visit

What happened during the October 7, 2022 survey of VISTA MANOR NURSING CENTER?

This was a inspection survey of VISTA MANOR NURSING CENTER on October 7, 2022. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at VISTA MANOR NURSING CENTER on October 7, 2022?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·October 7, 2022