Health inspection·January 31, 2022

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review, the facility failed to follow its own policy and procedure to report the allegations of resident-to-resident verbal abuse of two encounters, for two (Resident 4 and Resident 44) of 17 sampled residents to the California Department of Public Health (CDPH), the ombudsman and law enforcement immediately, but not later than 2 hours when: 1. Resident 4 was involved in an altercation on 7/29/21 at 6:00 p.m., 2. Resident 44 was involved in an altercation on 7/29/21 at 6:00 p.m. and 8/21/21 at noon. This failure had the potential to result in delay of investigation and the reporting of further allegations of abuse. 1. Review of Resident 4's admission record indicated Resident 4 was admitted with multiple diagnoses including cerebral infarction (a condition resulting from a lack of oxygen in the brain potentially causing a loss of sensory and motor function), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness such as mild loss of strength in a leg, arm, or face), acute kidney failure (kidneys suddenly become unable to filter waste products from the blood), and major depressive disorder (a mood disorder). Review of Resident 4's minimum data set (MDS, an assessment tool) indicated he had a brief interview for mental status (BIMS) score of 11 (a score of eight to 12 indicates the resident's cognition was mildly impaired) Review of Resident 4's IDT risk review dated 7/30/21 at 1:29 p.m. indicated .his roommate pushed his overbed table towards him and swung his fist at him . During an interview on 1/27/22 at 12:20 p.m. with Resident 4, Resident 4 stated there was an altercation with another resident (Resident 44) with words not physical. He was my roommate then, but we didn't agree on some of the music because it was not appropriate for all females. I think he was grieving some deaths in his family. After that we changed rooms. 2. Review of Resident 44's admission record indicated Resident 44 was admitted with multiple diagnoses including diabetes mellitus (a condition which affects the way the body processes blood sugar), end stage renal disease (kidneys no longer work as they should to meet your body's needs), atrial flutter (abnormal heartbeat), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and morbid obesity (weight is more than 80 to 100 pounds above their ideal body weight). Review of Resident 44's MDS dated [DATE] indicated he had a BIMS score of 12 (a score of eight to 12 indicates the resident is mildly impaired). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 2 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0609 Level of Harm - Minimal harm or potential for actual harm Review of Resident 44's IDT note dated 7/30/21 at 4:37 p.m. indicated .resident gestured as if he is going to hit him with his fist and pushed the overhead table toward him ., No physical contact was made. Review of Resident 44's IDT note dated 8/23/21 at 4:34 p.m. indicated, .this resident [Resident 44] is allegedly accused of verbally threatened another resident . Residents Affected - Few During an interview on 1/25/22 on 8:34 a.m. with Resident 44, Resident 44 stated, yes, I was placed with racist roommates. I had to raise my voice. My current roommate works well. During an interview on 1/25/22 at 1:55 p.m. with the administrator (ADM), the ADM stated, for abuse with no injury, we have 5 days to report. During concurrent interview and record review with the director of nursing (DON) on 1/27/22 at 8:59 a.m., Resident 44's progress notes were reviewed. The Change in Condition dated 8/21/21 at 12:12 p.m. indicated there was a verbal altercation with another resident. During an interview with the DON on 1/27/22 at 9:15 a.m., the DON stated for abuse reporting with no injury, we have 5 days to report. During an interview with ADM on 1/27/22 at 9:36 a.m., the ADM stated the State of California (SOC 341) Report of Suspected Dependent Adult/Elder Abuse for incident of alleged abuse dated 7/29/21 was not available. There is no documentation that the alleged verbal abuse was reported on form SOC 341 or by telephone. During review of State of California (SOC) Report of Suspected Abuse dated 8/22/21, the SOC indicated date/time of the incident was 8/21/21 around noon abuse: verbal threat. The facility notified CDPH and ombudsman by fax on 8/22/21 at 10:38 a.m. During review of the facility policy and procedure Abuse - Reporting and Investigation date revised 2/2020, the policy indicates .will notify law enforcement, LTC (long term care) ombudsman (assist residents in long-term care facilities with issues related to day-to-day care) and CDPH (California department of public health) licensing and certification immediately by telephone and in writing (SOC 341) as soon as possible, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 3 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interview and record review, the facility failed to notify one of six residents (Resident 19) and/or the resident's representative regarding the facility's policy for the bed hold when they were transferred to the hospital without receiving notice. This failure has the potential to violate the resident's right to allow the resident to return to the facility. Findings: Resident 19 was admitted to the facility with diagnoses included a history of Transient Ischemic Attack (TIA, similar to a stroke, but only lasts for a short duration), and cerebral infarction (disrupted blood flow to the brain, causing part of the brain to die off), chronic obstructive pulmonary disease (COPD, disease which causes airflow blockage and breathing-related problems), and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning). Review of Resident 19's electronic record (eRecord) indicated Resident 19 had a hospital leave which started on 9/25/21 and she had returned on 9/29/21. During an interview on 1/28/22 at 9:44 a.m. with the director of nursing (DON), DON stated she could not find documentation that a bed hold form was given to Resident 19 or her representative. During an interview on 1/28/22 at 10:03 a.m. with medical records staff (MR), MR stated she was trying to find the bed hold form for Resident 19. During an interview on 1/31/22 at 2:10 p.m. with MR, MR stated she could not find a bed hold form for Resident 19. During a review of the facility's policy and procedure titled Bed Holds, revised 02/2019, indicated, .1. Current regulations require that the facility provide/offer a bed-hold of up to 7 days when a resident is transferred to the acute hospital.3. Nurse supervisor/charge nurse or designee shall notify the resident/legal representative of his/her right to a bed-hold at the time of transfer to the hospital and complete the bed-hold notice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 4 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0641 Ensure each resident receives an accurate assessment. 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 accurately complete the Minimum Data Set (MDS, an assessment tool) for one of 17 sampled residents (Resident 1) and one resident (Resident 68). Failure to accurately assess had the potential to compromise the facility's ability to develop and implement resident-centered care plans and interventions. Residents Affected - Few Findings: 1. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a tool used to communicate information to the doctor) Communication Form and Progress Notes indicated she fell in the facility on 9/4/2020, 1/22/2021 and 3/12/2021. Resident 1's MDS, dated [DATE] and 4/17/2021 were reviewed. Section J1800 asked the question, Has the resident had any falls since admission/entry or reentry or the prior assessment? The answer to this question was coded 0 to indicate Resident 1 did not have any falls during the specified time frames. Resident 1's falls on 9/4/2020, 1/22/2021 and 3/12/2021 were not coded on the MDS. During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 1/28/2022 at 11:41 a.m., she reviewed Resident 1's medical record and confirmed the resident fell on 9/4/2020, 1/22/2021 and 3/12/2021. The MDSC stated the fall on 9/4/2020 should have been coded on the MDS dated [DATE]. She further stated the falls on 1/22/2021 and 3/12/2021 should have been coded on the MDS dated [DATE]. The MDSC confirmed none of the above falls were coded on the appropriate MDS. Review of the Centers for Medicare & Medicaid Services (CMS) 10/2019 Resident Assessment Instrument 3.0 User's Manual (RAI Manual, MDS coding instructions) indicated for section J1800, Code 1, Yes if the resident has fallen in the specified time frame. 2. Review of Resident 68's medical record indicated he was discharged from the facility on 10/29/2021. Review of Resident 68's Progress Notes, dated 10/29/2021, indicated the responsible party (RP, person designated to make decisions for the resident) decided to have Resident 68 discharged from the facility against medical advice (AMA, against the advice of the doctor). During an interview with the administrator (ADM) on 1/28/2022 at 2:13 p.m., he confirmed Resident 68 was discharged AMA, and this was considered an unplanned discharge. According to the ADM, the RP indicated he would be taking Resident 68 home. Resident 68's discharge MDS, dated [DATE] was reviewed. Section A0310 was coded 1 to indicate Resident 68's discharge was planned. Section A2100 was coded 03 to indicate Resident 68 was discharged to the acute hospital. During an interview and concurrent record review with the MDSC on 1/28/2022 at 2:26 p.m., she confirmed if Resident 68 was discharged AMA, the MDS should have indicated it was an unplanned discharge. She also confirmed if Resident 68 was discharged home, the MDS should have indicated he was discharged to the community, not to the acute hospital. The MDSC acknowledged Resident 68's 10/29/2021 MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 5 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0641 was not coded accurately. Level of Harm - Minimal harm or potential for actual harm Review of the CMS 10/2019 RAI Manual indicated for section A0310, Code 2: if type of discharge is an unplanned discharge. The RAI Manual further indicated for section A2100, Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility, or group home. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 6 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 interview and record review, the facility failed to provide adequate supervision and security for one of three residents (Resident 47) when facility staff was unaware Resident 47 wandered away outside the facility for several hours. This failure compromised the resident's safety and put her at high risk for injury. Residents Affected - Few Findings: During record review of Resident 47's clinical record, Resident 47 was admitted on [DATE] with diagnoses included dementia (memory loss), diabetes mellitus (high blood sugar) and osteoporosis (a condition in which bones become weak and brittle). Review of Resident 47's minimum data set (MDS, a resident assessment tool) dated 12/08/21, indicated Resident 47 was severely cognitively impaired and required supervision during activities of daily living (ADLs). Review of Resident 47's elopement risk assessment dated [DATE], indicated Resident 47 was at risk for elopement. During interview with licensed vocational nurse (LVN E) on 01/28/22 at 1:30 p.m., LVN E stated he was not aware Resident 47 was at risk for elopement (wandering). Resident 47 was gone for some time between 12:00 p.m. to 3:00 p.m. on 12/12/21. A police officer came to the facility to return Resident 47 as she was found in the street. LVN E further stated that nursing aides also did not know the whereabouts of Resident 47. Review of Resident 47's clinical record revealed there was no evidence documentation indicated staff checked frequently (or at regular intervals) as to the whereabouts of Resident 47. During interview with the director of staff development (DSD), on 1/28/22 at 1:35 p.m., DSD acknowledged the lack of documentation that staff checks frequently at regular intervals the whereabouts of Resident 47, and stated there should have been evidence of documentation that staff checks on her frequently. Review of Resident 47's social services note dated 12/12/21, indicated Elopement: About 3:25 p.m., the dayshift nurse came to social services director (SSD) to alert an officer is here. SSD allowed police officer to enter. He stated a good Samaritan found a lady and asked her where she lives. The Samaritan told officer she lives at (the facility name) down the street. The police officer showed SSD a cellphone picture of Resident 47 inside the car for [sic] the person driving. According to police officer the 2nd officer could not get resident to get the patrol vehicle. They decided to keep her in the car. The car arrived and SSD directed staff to come take her inside the facility. During interview with the director of nursing (DON) on 01/28/22 at 02:45 p.m., the DON stated Resident 47 was gone between 1 to 3 p.m. DON thought that Resident 47 had passed by along with the residents who went out to smoke in the designated area. The alarm was off at the time. Staff had overlooked Resident 47 who went out to the street and staff was unaware of the incident until the police returned the resident to the facility. The facility did not report the incident to the California Department of Public Health. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 7 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Resident 47's care plan related to elopement risk revised on 9/02/21, indicated Observe location at regular and frequent intervals. Document wandeering behavior and attempted diversional interventions. Orient resident to environment. Reorient/validate and redirect resident as needed. Wanderguard on the right wrist to alert staff when resident is trying to get out of facility unassisted . Review of the facility's revised policy and procedure titled Elopement dated 7/2012, indicated .Should an employee observe a resident leaving the premises, he/she should: a. Attempt to prevent the departure; b. Obtain assistance from other staff members in the immediate vicinity, if necessary; .5. Upon return of the resident to the facility, the director of nursing services or charge nurse should .Complete and file an investigation report; Event ID: Facility ID: 555635 If continuation sheet Page 8 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow its own policy and procedure to evaluate residents' fall risk, to investigate the fall, to implement resident centered care plan, to revise the fall care plan and/or place the effective interventions to prevent four of 17 sampled residents (Residents 1, 24, 37 and 38) from multiple falls recurring when: 1. For Resident 1, the facility did not revise the fall care plan, did not implement fall care plan intervention or evaluate the resident's fall risk. Resident 1 had eight (8) unwitnessed falls from 5/21/2020 to 1/25/2022. 2. For Resident 24, the facility did not revise the fall care plan, did not implement fall care plan intervention or evaluate the resident's fall risk. Resident 24 had four (4) unwitnessed falls from 9/11/2021 to 1/8/2022. 3. For Resident 37, staff failed implement the fall care plan intervention to provide dycem (non-slip mat) on his wheelchair, which had resulted in Resident 37 sliding on his wheelchair and falling on the floor on 8/17/21. Resident 37 sustained an abrasion on his chin. Resident 37 had eight (8) falls from 8/16/21 to 1/23/22. 4. For Resident 38, staff failed to provide frequent checks on Resident 38, which had resulted in Resident 38's fall onto the floor lying on her back and sustaining a hematoma (a bad bruise, it happens when an injury causes blood to collect and pull under the skin) on her right scalp on 6/17/21. Resident 38 had nine (9) falls from 5/20/21 to 12/31/21. These failures resulted in the residents' continued falls and resulted in fall injuries. Resident 1 had a left humerus fracture (upper arm break) from the 6th fall on 6/21/2, a head contusion (a bruise) from the seventh fall on 11/19/21 and head laceration from the eighth fall on 1/25/22. Resident 24 had a fourth fall on 1/8/22 with a closed fracture of second thoracic vertebra (middle part of back that connects to ribs). Resident 37 had a sustained abrasion on the chin from the fall on 8/17/21. Resident 38 had a sustained hematoma on the right scalp from the fall on 6/17/21. Findings: 1. During a review of Resident 1's clinical record it indicated she was admitted with multiple diagnoses including hypertension (high blood pressure), dementia with behavior disturbance (decline in mental capacity affecting daily function and impairs reasoning), unspecified psychosis (a mental disorder characterized by a disconnection from reality). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 12/2/21, it indicated Resident 1's mental status evaluation revealed moderate impairment. During a review of Resident 1's clinical record it indicated Resident 1 had falls on the following dates: 5/21/20, 9/4/20, 10/29/20, 1/22/21, 3/12/21, 6/21/21, 11/19/21 and 1/25/22. During a review of Residents 1's clinical record, the fall risk assessments dated 4/9/20, 7/17/20, 5/21/20, 9/5/20, 10/17/20, 10/29/20, 3/12/21, 4/17/21, 6/21/2, 11/19/21, and 1/30/22 indicated Resident 1 was a high risk for falls. Resident 1's 1/22/21 fall risk assessment indicated low risk for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 9 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0689 falls. Level of Harm - Actual harm Review of Resident 1's Minimum Data Set (MDS) dated [DATE], the annual review indicated Resident 1 was able to perform Activities of Daily Living (ADLs) with supervision and set-up to one person assist. Following the fall on 6/21/21 the MDS dated [DATE] indicated the performance of ADLs was with extensive assistance and two person assist with total dependence. Residents Affected - Few During a review of Resident 1's fall risk care plan dated 4/9/20 indicated Resident 1 is high risk for falls, interventions included; 1. Anticipate resident's needs. 2. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all request for assistance. 3. Educate resident the use of call button for assistance and not to get up from bed or wheelchair unassisted 4. Refer to rehab. 5. Ensure nonskid socks when ambulating or mobilizing in wheelchair. 6. The resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare free light, a working and reachable call light, the bed in low position at night, side rails as ordered, handrails on walls, personal items within reach. 7. The resident's bed will keep in the lowest position. a. During a review of Resident 1's Interdisciplinary Team (IDT a group of health care professionals from diverse fields who work toward a common goal for residents) note dated 5/22/20 at 1:00 p.m., indicated Resident 1 had an unwitnessed fall on 5/21/20 at 5:10 p.m. [Resident 1] was found sitting on the floor of her room. Resident stated, I was getting my rosary under my bed, but I slid on the floor. No injuries. Predisposing diseases indicated Dementia /Alzheimer's disease and other: difficulty in walking, muscle weakness. Conditions that contributed to the fall were listed as: unsteady gait. IDT recommendations indicated Resident is alert and wishes to be independent. She has weakness on her bilateral lower extremities and is at high risk for fall. Resident is educated on the use of call light and not to get up unassisted. Care plan revision and referral to physical therapy. Other intervention recommendations: PT (physical therapy) evaluation with focus on safety, recommended and given a reacher (tool for reaching), educated how to use. Frequent reminders to call for assistance when she drops something on the floor, not to attempt to pick it up. During a review of Resident 1's clinical record, the Fall Risk assessment dated [DATE] at 10:45 p.m. indicated Resident 1's level of consciousness (awareness)/mental state was alert, had 1-2 falls in past three months and was a high risk for falls. During a review of Resident 1's fall risk care plan dated 5/21/20 and 5/22/20 indicated Resident 1 was found on the floor, beside her bed, interventions included 1. Frequent reminders to call for assistance if she drops something on the floor and not to attempt to reach down for it. 2. Keep personal items within easy reach. 3. Assess neurological (brain) status and vital signs, notify MD for any significant abnormal changes. 4. Assess resident's immediate needs for toileting, need for food, thirst or in pain, reaching for something, educate resident the use of call light for assistance and not to get up unassisted 5. Provide resident with a reacher and educate her on how to use it. 6. PT eval with focus on safety. b. During a review of Residents 1's IDT note dated 9/9/20 at 1:00 p.m., the IDT note indicated Resident 1 had an unwitnessed fall on at 9/4/20 at 4:00 p.m., Resident 1 .had fallen in her room at the bedside sometime early evening of 9/4/20.landed on knees and had to turn to a sitting position for her to get back to bed. No injury. Predisposing diseases indicated Dementia/Alzheimer's disease and other: psychosis, difficulty walking, muscle weakness. Conditions that may contributed to the fall were listed as: history of falls, cognitive deficits (an inclusive term used to describe an impairment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 10 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0689 Level of Harm - Actual harm Residents Affected - Few of how individual's mentally processes information), and recurrent dizziness with episodes of double vision. IDT recommendations indicated resident has recurrent complaint of dizziness and double vision. Also having episode of auditory and visual hallucinations (perception of something not present). Ambulatory with forward wheel walker. Care plan revision and referrals to occupational therapy. Other intervention recommendations included: occupational therapy evaluation and treat with focus on safety. Assess resident for dizziness and double vision and instruct resident to stay in bed if symptoms persist. Review of Resident 1's Fall Risk assessment dated [DATE] at 10:19 a.m., the fall risk assessment indicated Resident 1's level of consciousness/mental state was alert, had 1-2 falls in past three months and was a high risk for falls. During a review of Resident 1's fall risk care plan dated 9/5/20, 9/8/20 and 9/9/20, the care plan indicated Resident 1 claimed fall in her room, interventions included; 1. Assess the resident and instruct her to stay in bed if dizziness and double vision present. 2. Guarantee appropriate room lighting especially during the night. 3. Move items used by resident within easy reach, such as call light . 4. Notify MD (medical doctor) and RP (responsible party). 5. OT (occupational therapy) evaluation and treat if indicated. 5. Respond to call light as soon as possible. 6. Teach client how to safely ambulate (walk), including using safety measures such as handrails in bathroom. During a review of Resident 1's fall care plan dated 9/5/20, 9/8/20 and 9/9/20, the care plan indicated no evidence that the facility addressed cognitive deficits that may have contributed to the fall as indicated in IDT note dated 9/9/20 at 1:00 p.m. c. During review of Resident 1's IDT note dated 10/29/20 at 3:53 p.m., the IDT note indicated Resident 1 had an unwitnessed fall on 10/29/2020 at 4:00 a.m. Staff responded to a loud noise coming from the residence room and noted the resident lying on the floor in supine position between the bed and over bed table . According to the resident she was trying to sit at the edge of her bed . slid down to the floor. she complained of pain at the back of the left ear 3/10, no injury. Conditions that contributed to the fall were listed as: history of falls, cognitive deficits, and episodes of confusion (decreased alertness), dizziness, and double vision. IDT recommendations indicated: Resident has episodes of dizziness and double vision but denies having them prior to this event. Was wearing nonskid socks, floor dry, room well light and height of bed in lowest position. Care plan revision and referrals to physical therapy and occupational therapy. other intervention recommendations physical therapy and occupational therapy referral with focus on safety. During review of Resident 1's Fall Risk assessment dated [DATE] at 4:33 a.m., the fall risk assessment indicated Resident 1's level of consciousness /mental state was intermittent confusion, had 1-2 falls in past three months and was a high risk for falls. During review of Resident 1's fall risk care plan dated 10/29/20, the care plan indicated Resident 1 had an actual fall interventions included 1. Encourage resident to ask for assistance. 2. Neuro checks (assessment of the brain) for three days. 3. Observe/document/report PRN (as needed) for 72 hours to MD for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture (position in which someone holds their body when standing or sitting), agitation (state of anxiety or nervous excitement). 4. Place frequently used items in reach. 5. Refer to rehab PT/ OT with focus on safety. During a review of Resident 1's fall care plan dated 10/29/20, the care plan indicated no evidence (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 11 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0689 Level of Harm - Actual harm that the facility addressed cognitive deficits and episodes of confusion that were indicated in the IDT note dated 10/29/20 at 3:53 p.m. as conditions that may have contributed to Residents 1's fall risk or the intermittent confusion indicated on the Fall Risk assessment dated [DATE] at 4:33 p.m. that increased Resident 1's risks for fall. Residents Affected - Few During a review of Resident 1's fall care plan, dated, 10/29/20, the care plan indicated no evidence of new interventions were created in order to prevent future falls. d. During a review of Resident 1's IDT note dated 1/22/21 at 1:50 p.m., the IDT note indicated Resident 1 had an unwitnessed fall on 1/22/21 at 1:50 p.m. resident had fallen on the floor. Resident stated she wants to use the commode and cannot get anyone to help her, and she then got up from her bed unassisted and fell. No injury noted. Conditions that may have contributed to the fall were listed as: unsteady gait and history of falls. IDT recommendations indicated, resident has generalized weakness on bilateral lower extremities. At times she wishes to be independent, impulsive and does not want to call for assistance. Care plan revision and referral to physical therapy. Other intervention recommendations encourage resident not to get up unassisted and use call bell for assistance. Anticipate residents' basic needs. During review of Resident 1's SBAR communication form dated 1/22/21 at 2:01 p.m., the SBAR indicated things that make the condition worse are resident at risk of not using her call button or ask for help due to diagnosis of dementia. During review of Resident 1's Fall Risk assessment dated [DATE] at 4:14 p.m. indicated Resident 1's level of consciousness/mental state was alert, had no falls in past three months and was a low risk for falls. During review of Resident 1's fall risk care plan dated 1/22/21, the care plan indicated Resident 1 had an unwitnessed fall. Interventions included 1. Notify MD and RP. 2. Assess for injury. 3. Assessed for pain and medicate. 4. Encourage the use of call button and not to get up unassisted. 5. Anticipate and assist basic needs: toileting, food, thirst, medicate for pain, reaching out down. During review of Resident 1's clinical record no evidence was provided on how the facility anticipated Resident 1's needs for toileting, food, thirst, medicate for pain, reaching out down, an intervention indicated on care plan dated 1/22/21. During a review of Resident 1's fall care plan, dated 1/22/21, the care plan indicated no evidence of new interventions were created in order to prevent future falls. During review of Resident 1's fall care plan, dated 1/22/21, the care plan indicated no evidence the facility addressed resident at risk of not using her call button or asking for help due to diagnosis of dementia as indicated on Resident 1's SBAR dated 1/22/21 at 2:01 p.m. that contributed to the fall. e. During review of Resident 1's IDT note dated 3/15/21 at 11:56 a.m., the IDT note indicated Resident 1 had an unwitnessed fall on 3/12/21 at 3:48 p.m.resident with sitting on the floor at the bedside. According to resident she was about to sit at the edge of her bed, but she was already sliding and could not control it, so she slowly eased herself down to the floor. No injury noted, complaint of pain 4/10 on right hip. Predisposing diseases indicated Dementia /Alzheimer's disease and other: psychosis, difficulty walking, weakness. Conditions that contributed to the fall: history of falls, cognitive deficits. IDT recommendations indicated resident is ambulatory with forward wheeled walker (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 12 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0689 Level of Harm - Actual harm (FWW). Has muscle weakness and difficulty walking. Has impaired safety judgment and is impulsive. Care plan revision. Referrals to physical therapy and occupational therapy. Other intervention recommendations refer to physical therapy and occupational therapy with focus on safety. Remind resident to slow down and maintain balance prior to standing or sitting activity. Residents Affected - Few During review of Resident 1's Fall Risk dated 3/12/21 at 4:08 p.m., the fall risk indicated Resident 1's level of consciousness/mental state was intermittent confusion, had three or more falls in past three months and was a high risk for falls. During review of Resident 1's fall risk care plan dated 3/12/21 and 3/15/21, the care plan indicated Resident 1 slid on the floor in her room related to impulsiveness, unable to slow down, muscle weakness pain and impaired safety judgment interventions included 1. Neuro check per facility protocol 2. Note for any pain and discomfort, offer pain medications as needed. 3. Notify MD. 4. Placed belongings and call light within reach. 5. Refer to therapy with focus on safety. 6. Remind resident to slow down, control her balance prior to standing or sitting. During review of Resident 1's fall care plan dated 3/15/21, the care plan indicated no evidence the facility addressed Resident 1's cognitive deficits, impaired safety judgment and impulsiveness as indicated in the IDT note dated 3/15/21 at 11:56 a.m. and level of consciousness/mental state of intermittent confusion indicated Fall Risk dated 3/12/21 at 4:08 p.m. that increased Resident 1's risk for falls. f. During review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation, an assessment tool used to facilitate prompt and appropriate communication of a problem) Communication form dated 6/21/21 at 10 p.m. indicates Resident 1 had an unattended fall on 6/21/21 (time not indicated), with complaints of pain on left shoulder. SBAR also indicated things that make the condition worse are resident does not use call light for assistance, not using FWW when ambulating. During review of Resident 1's SBAR Follow-up dated 6/22/21 at 12:49 a.m. indicated at 8:15 p.m. loud bang in the hallway and resident (Resident 1) yelling help, help .resident laying on her left side on the floor in the hallway by the residence room facing the nursing station. Complain of pain on arm pointing to left mid upper arm she was standing by her door looking for nurse, turned around to go back to her room, her legs felt shaky and fell landing on her left arm. During review of Resident 1's Fall Risk dated 6/21/21 at 10:40 p.m. it indicated Resident 1's level of consciousness/mental state was intermittent confusion, had 1-2 falls in past three months and was a high risk for falls. During review of Resident 1's Nursing progress notes dated 6/22/21 at 8:17 a.m. indicated resident was complaining of severe pain of the left shoulder .there was obvious swollen as well as bruising. Xray results: Comminuted minimally displaced left humeral neck and head fracture (broken upper arm bone). Resident 1 left the facility at 5 a.m. to the Emergency Department. During review of Resident 1's Emergency Department visit summary dated 6/22/21 at 1:42 p.m. indicated Resident 1's diagnosis was: Closed displaced fracture of surgical neck of left humerus .Acute cystitis (inflammation of the urinary bladder) .Resident was given a sling [a device to limit movement of the shoulder or elbow while it heals] . During review of Resident 1's Nursing progress notes dated 6/22/21 at 9:52 p.m. indicated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 13 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0689 Level of Harm - Actual harm Residents Affected - Few 1 arrived at 7:00 p.m.with complaint of pain of the left shoulder and arm due to fracture of left humerus due to fall left shoulder warm to touch and appear swelling with no redness .resident with new diagnosis of UTI [urinary tract infection] During review of Resident 1's fall risk care plan dated 6/22/21and 6/23/21, indicated Resident 1 had an actual fall. Interventions included 1. Assess severity of pain and offer medication as ordered. 2 Follow-up with orthopedics in a week. 3. Keep left upper extremity in sling provided by the ER 4. Maintain left upper extremity in proper alignment. 5. Monitor swelling and bruising of left upper extremity and notify MD if significantly worse or if there is skin opening. 6. PT/OT evaluation and treat with focus on safety. 7. Administer pain medication as ordered, notify MD of unrelieved pain. 8. Encourage and reorient to the use of call light when help is needed. 9. Notify RP and MD. 10. Remind resident to always use forward wheeled walker when ambulating. 11. Send resident to acute hospital per MD order. 12. Start left shoulder X ray due to pain. 13. Transfer to hospital ER via ambulance for further evaluation on fall. During review of Resident 1's fall care plan dated 6/22/21 and 6/23/21, the care plan indicated no evidence the facility addressed Resident 1's intermittent confusion as indicated in Fall Risk dated 6/21/21 at 10:40 p.m. that increased Resident 1's risk for falls. During review of Resident 1's care plan dated 6/22/21 indicated to remind the resident to use the walker, following the fall on 6/22/21 resident had pain in the left arm, was diagnosed with a broken bone and according to nurses notes the resident was using a sling. During review of Resident 1's IDT weekly At Risk meeting note dated 6/24/21 at 2:17 p.m. indicated resident had a fall 6/21/21, while she was turning in the hallway, claimed her leg became shaky while turning back towards her room, causing her to fall on her left side, complain of pain 6/10, had swollen and bruising on the area, X ray revealed comminuted mildly displaced fracture left humeral neck and head, she was sent to the ER for further evaluation and follow up. Sling was applied to the left upper extremity. Offered medication for pain. Continue with auditory hallucination .Resident has intermittent confusion usually ambulate with forward wheel walker (FWW) but did not use during the fall, reminded to use the forward wheel walker. Physical therapy and occupational therapy evaluation and treatment. Started on antibiotic for UTI till 6/29/21. Care plan reviewed and updated. During review of Resident 1's IDT risk review note dated 7/26/21 at 5:18 p.m. indicated, . decline in late loss ADL, falls with major injury and range of motion (ROM) limitations receiving services. Residents' prior function was independent to supervision. She previously [was] able to ambulate around with FWW. Recently she had a fall while trying to turn back to her room and her legs weakened and fell on the floor on her left side to staining fracture of her left humeral neck and head. Left upper extremity is immobilized with a splint. She had a decline in function since requiring extensive assistance with bed mobility, transfer, bathing and dressing due to pain and ROM limitations of the upper extremity . g. During review of Resident 1's change in condition notes dated 11/19/21 at 10:00 a.m. indicated Resident 1 had a fall on 11/19/21 with injury: bump to back of lower head. During review of Resident 1's nursing notes dated 11/19/21 at 11:15 indicated at around 9:45 a.m., Resident 1 was noted sitting on the floor, facing her bed, walker on her side .noted bump on back of head approximately 2.5x 2.5 centimeters (cm., unit of measurement), skin intact, no bruising noted. At around 10:34 a.m. resident complained three out of 10 pain on bump site, medicated for pain. Per resident she was standing up and fixing her personal belongings on her table when she got out of balance and fell. Nursing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 14 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0689 notes dated 11/19/21 at 10:53 indicated, .nurse and received an order to send the resident to the hospital for further evaluation. Level of Harm - Actual harm Residents Affected - Few During review of Resident 1's Emergency Department note: Discharge summary dated [DATE] at 11:52 indicated Resident 1 presented with fall. Patient reports that she was trying to get up from bed and her legs gave out, she fell on the side hitting her head on the side table. Denies any LOC . Complaining of pain in her back, left sided chest wall, left shoulder (acute on chronic). 8 to 10 hours into emergency visit, patient went into a period of A Fib with RVR (abnormal heartbeat) heart rate in the 140s. Patient otherwise asymptomatic .heart rate controlled . discharged Condition stable. Discharge diagnosis: principal problem: fall During review of Resident 1's clinical record there was no evidence the facility completed an IDT note following Resident 1's fall on 11/19/21. During review of Resident 1's Fall Risk assessment dated [DATE] at 11:34 a.m. it indicated Resident 1's level of consciousness/mental state was intermittent confusion, had 1 to 2 falls in the past three months and was a high risk for falls. Review of Resident 1's fall risk care plan dated 11/19/21 indicated Resident 1 had an actual fall related to poor balance. Interventions included 1. Provide activities that promote exercise and strength building where possible provide one to one activities if bedbound. 2. PT (physical therapy) consult for strength and mobility. 3. Continue interventions on the at-risk plan. 4. Monitor/ document /report PRN (as needed) times 72 hours to MD (medical doctor) for signs and symptoms of pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, agitation. 5. Neuro checks. Review of Resident 1's fall care plan dated 11/19/21 indicated there was no evidence the facility addressed Resident 1's intermittent confusion as indicated in Fall Risk dated 11/19/21 at 11:34 a.m. that increased Resident 1's risk for falls. h. Review of Resident 1's IDT Fall Review dated 1/26/22 at 9:32 p.m. indicated the resident had an unwitnessed fall on 1/25/22 on the evening shift. Resident 1 was asked what happened and she said she tried to sit on her walker after she finished brushing her teeth in the bathroom in her room, but the walker was not locked, causing her to fall. Resident 1 sustained a small laceration on the occipital (position at the back of the head) area of her head and was sent to the ER for further evaluation and treatment. Resident 1 returned from the ER and no abnormal findings were noted. IDT recommendation was to encourage the resident to use call light when she needs assistance, physical therapy will screen . Review of Resident 1's nursing note dated 1/26/22 at 12:59 a.m. indicated, .what happened, I was about to go back to my room, I turned around and my walker shift to side and fell. Resident went to bathroom unassisted and without calling for staff assist. Review of Resident 1's Fall Risk assessment dated [DATE] at 11:56 p.m. indicated Resident 1's level of consciousness/mental state was intermittent confusion, had 1-2 falls in past three months and was a high risk for falls. During review of Resident 1's Fall Risk assessment dated [DATE] at 3:53 p.m. indicated Resident 1's level of consciousness/mental state was disoriented x three at all times, had 1-2 falls in past (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 15 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0689 three months and was a high risk for falls. Level of Harm - Actual harm Review of Resident 1's fall risk care plan dated 1/25/22 indicated Resident 1 had actual fall interventions including, 1. Apply pressure to laceration site to stop bleeding. 2.Transfer to hospital for further evaluation and treatment. 3. Head to toe skin check. 4. Neuro checks started. Residents Affected - Few Review of Resident 1's fall care plan dated 1/25/22, indicated no evidence the facility addressed Resident 1's intermittent confusion as indicated in Fall Risk dated 1/25/22 at 11:56 p.m. and disoriented x three on 1/30/22 at 3:53 p.m. that increased Resident 1's risk for falls. Review of Resident 1's fall care plan dated 1/25/22, indicated no evidence the facility addressed the interventions to decrease Resident 1's risk of falls. Review of Resident 1's clinical record indicated there was no evidence the facility completed weekly at risk review meetings for all of the falls mentioned above. During observation and interview on 1/25/22 at 8:26 a.m., Resident 1 was in her bed, the bed in a low position, the call light withinin reach. Resident 1's room contained many of her belongings. Resident 1 stated she has many pretty clothes and pictures from home. She stated she hurt her arm when she fell, it still hurts. During an interview on 1/26/22 at 1:41 p.m. Registered Nurse H (RN) stated Resident 1 had a fall last night when she went to the bathroom by herself. During an observation and interview on 1/26/22 at 1:56 p.m. in Resident 1's bathroom with certified nursing assistant I (CNA) Resident 1's bathroom was observed to have two wheelchairs placed in corners of the bathroom. CNA I stated the wheelchairs should not be stored there. During interview on 1/26/22 at 2:23 p.m. with the Minimum Data Set Nurse Coordinator (MDSC), MDSC stated an At Risk for Fall assessment is done after every fall, based on the assessment, higher numbers mean better intervention is needed, if other interventions are not working. Need to find what is causing the fall, the root cause, that helps come up with better interventions. A concurrent interview and record review was done with MDSC on 1/26/22 at 2:47 p.m. with Resident 1's clinical record. Review of the clinical record indicated an IDT note was not completed following Resident 1's fall on 11/19/21. MDSC verified the IDT note was not completed and stated, there is no active care plan specific on how to prevent Resident 1's fall risk. During interview on 1/27/22 at 4:19 p.m. with licensed vocational nurse J (LVN), LVN J stated she was working on 1/25/22 when station 1 called her because there was a loud noise and Resident 1 was found on the floor. She did not call prior to getting up. During interview on 1/27/22 at 4:25 p.m., LVN J stated she was working on 6/21/21 when Resident 1 had the fall, and she broke her arm. LVN J stated most of the time she did not use the call light, we remind her, it doesn't work (reminding her). During interview on 1/28/22 at 11:54 a.m. with he rehab program director (RPD), RPD stated Resident 1 had a decline in her ADL because of limited use of her arm. She could not use the walker with her arm as she was in pain and had a sling. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 16 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0689 Level of Harm - Actual harm Residents Affected - Few During interview on 1/31/22 at 3:52 p.m. with MDSC, MDSC stated Physical therapy/Occupational (PT/OT) alone is not sufficient to address the fall. Therapy (PT/OT) addresses ADLs and makes recommendations with other disciplines to address problems and coordinate care. During concurrent interview and record review on 1/31/22 at 3:36 p.m. of Resident 1's clinical record, with MDSC and the DON. MDSC stated it is important to get to the root cause. Is it cognition, needing to go to the bathroom, find the cause to get appropriate interventions for that resident. MDSC verified there are no changes in the interventions, they are repeated after each fall. During interview on 1/31/22 at 3:47 p.m. with MDSC, she stated the licensed nurse incorrectly entered information in the Fall Risk assessment dated [DATE] at 4:14 p.m. indicating no falls in the past three months. Resident 1 had a fall in October 2020. Fall risk assessment completed 1/22/21 indicated Resident 1's fall risk is low risking following her fourth fall. Resident 1 had a fall on 10/29/20. During a review of the facility's policy and procedure titled Accidents and Incidents - Investigating and Reporting dated revised 4/2016, The residents care plan will be amended to include immediate interventions if applicable and subsequent interventions During a review of the facility's policy and procedure titled Fall Management dated July 2017, the policy indicated, The IDT evaluates each resident's fall risk. A care plan is developed and implemented, based on this evaluation, with ongoing review .the facility is obligated to investigate .and put into place an intervention to minimize it from recurring. Review of the facility's revised policy and procedure of Fall Management dated November 2017, indicated .The IDT should choose a consistent day of the week for the At Risk Review Meeting .Residents who have experienced actual falls will be reviewed each week during the At Risk Review Meeting .The At Risk Review committee members will review residents with falls for documentation, compliance, and interventions on a weekly basis .After the At Risk Review Meeting, the IDT will perform the follow-up items assigned as indicated by the review . 2. During review of Resident 24's clinical record, it indicated she was admitted with multiple diagnoses including Iron deficiency anemia (blood has a lower-than-normal number of red blood cells), syncope (temporary loss of being awake and aware of one's surroundings) and collapse (falling down), hypertension (high blood pressure) and a history of falling. Review of Resident 24's Minimum Data Set (MDS, an assessment tool), dated 9/1/21, it indicated Resident 24's mental status evaluation revealed moderate impairment. During review of Resident 24 's clinical record, the clinical record indicated Resident 24 had falls on the following dates: 9/11/21, 9/26/21, 11/10/21 and 1/8/22. Review Residents 24's fall risk assessments dated 3/16/19, 9/11/21, 9/26/21, and 1/9/22, indicated Resident 24 was at high risk for falls due to multiple problems including interm[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 17 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 routinely assess the arteriovenous fistula (AV fistula, a connection surgically made between an artery and a vein for dialysis access) for one of three sampled residents (Resident 22) who received dialysis (a procedure in which a machine filters wastes and fluid from the blood). This failure had the potential to result in unidentified complications with Resident 22's AV fistula. Residents Affected - Some Findings: Review of Resident 22's medical record indicated she was admitted on [DATE] and had the diagnosis of end stage renal disease (ESRD, the kidneys no longer function as they should to meet the body's needs). The medical record further indicated Resident 22 received dialysis every Tuesday, Thursday and Saturday. Review of Resident 22's Order Summary Report indicated she had a physician's order dated 10/30/2021, to check dialysis site for bleeding, redness and tenderness every shift. She also had a physician's order dated 10/29/2021, to auscultate bruit (use a stethoscope and listen for a swishing sound) and palpate for thrill (use the fingers to feel for vibration) of the left AV fistula every shift. During an observation and concurrent interview on 1/28/2022 at 8:26 a.m., Resident 22 was sitting up in bed. Her AV fistula was located on her left upper arm. Resident 22 stated the nurses assessed her AV fistula sometimes. When asked if the nurses looked at the AV fistula every shift, Resident 22 stated, No. When asked if the nurses felt the AV fistula with their hands and listened to it with their stethoscopes every shift, Resident 22 stated, No. Review of Resident 22's treatment administration record (TAR) indicated from 11/1/2021 to 1/27/2022, there were 24 shifts for which there was no documentation that the nurses checked Resident 22's dialysis access site for bleeding, redness and tenderness. During the same time frame, there were also 24 shifts for which there was no documentation that the nurses auscultated bruit and palpated for thrill of Resident 22's left AV fistula. During an interview and concurrent record review with the unit manager (UM) on 1/28/2022 at 9:16 a.m., the UM reviewed Resident 22's TAR and confirmed there were many shifts for which the nurses did not document they assessed Resident 22's AV fistula as ordered. The UM stated if it was not documented, it was not done. Review of the facility's policy titled Renal Dialysis, Care of Residents, reviewed 11/2017, indicated to inspect the dialysis access site for color, warmth, redness, edema (swelling), pain and drainage every shift. The policy indicated to check for bruit once per shift and notify the physician immediately for any changes. The policy further indicated, Place your fingertips lightly over the access vein and feel for the thrill. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 18 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 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 provide pharmaceutical services to meet the needs of each resident when: Residents Affected - Some 1. The facility did not reorder two out of 12 emergency medication kits (E-kits) after using them; and 2. The facility failed to ensure controlled medications (medications regulated by the government because they may be abused or cause addiction) for four out of six residents (Residents 31, 371, 20 and 66) were accounted for. Failure to reorder the E-kits had the potential to result in medications not being available to the residents when needed. Failure to account for controlled medications had the potential to result in diversion (transfer for illicit use) of the medications. Findings: 1. During an observation on 1/24/2022 at 10:12 a.m., one E-kit containing narcotic medications (medications that dull the senses and have the potential to cause addiction) was inspected. The medication list on the outside of the E-kit indicated there were supposed to be eight tablets of Dilaudid (pain medication) 2 milligrams (mg, unit of dose measurement), eight tablets of Oxycodone (pain medication) 5 mg, and eight tablets Norco (pain medication) 5/325 mg. There were only seven tablets of each of these medications inside the E-kit. Review of the facility's Emergency Kit Pharmacy Log (record of medications removed from the E-kit) indicated a licensed nurse removed one tablet of Dilaudid 2 mg on 12/15/2021, one tablet of Oxycodone 5 mg on 12/27/2021, and one tablet of Norco 5/325 mg on 1/2/2022. During an interview with the unit manager (UM) on 1/24/2022 at 10:12 a.m., she confirmed the above observations and confirmed the licensed nurses did not reorder the E-kit after removing the medications. The UM stated after taking medication out of the E-kit, the licensed nurse should order a replacement from the pharmacy right away. During an observation on 1/24/2022 at 10:26 a.m., one E-kit containing assorted medications was inspected. The medication list on the outside of the E-kit indicated there was supposed to be one vial (small cylindrical container) of Nitroglycerin (medication used to treat chest pain) 0.4 mg. There were zero vials of Nitroglycerin 0.4 mg inside the E-kit. Review of the Facility's Emergency Kit Pharmacy Log indicated a licensed nurse removed the vial of Nitroglycerin 0.4 mg from the E-kit on 12/13/2021. During an interview with the UM on 1/24/2022 at 10:26 a.m., she confirmed the above observations and confirmed the licensed nurse did not reorder the E-kit after removing the Nitroglycerin 0.4 mg. The UM acknowledged if a resident needed emergency Nitroglycerin, it would not have been available in the E-kit. During an interview with the consultant pharmacist (CP) on 1/31/2022 at 8:30 a.m., he stated when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 19 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 medications are taken out of the E-kit, the E-kit should be replaced within 72 hours. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Pharmacist Consultant Summary Report, dated 1/7/2022 indicated, E-kit sticker must be faxed to the pharmacy after the E-kit is used, as the pharmacy will not replace the E-kit automatically. E-kits must be replaced within 72 hours after opening. Residents Affected - Some The facility's policy titled Medication Ordering and Receiving from Pharmacy, dated 8/2014 indicated, If exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours after opening. 2. Review of Resident 31's medical record indicated he had a physician's order, dated 11/28/2020, for Norco 5/325 mg one tablet by mouth every eight hours as needed for moderate to severe pain. Review of Resident 31's Controlled Drug Record (document used to keep track of the quantity of a controlled medication the resident has in supply) indicated a licensed nurse removed one tablet of Norco 5/325 mg from Resident 31's supply on 10/4/2021 at 6:00 p.m., 10/10/2021 at 6:00 p.m., 12/26/2021 at 1:00 p.m., 12/29/2021 at 11:00 a.m., and 1/4/2022 at 12:10 a.m. Review of Resident 31's medication administration record (MAR) dated 10/2021, 12/2021 and 1/2022, indicated there was no documentation that he received Norco 5/325 mg on the above dates and times. Review of Resident 371's medical record indicated she had a physician's order, dated 1/16/2022, for Oxycodone 5 mg one half tablet (2.5 mg) by mouth every six hours as needed for moderate pain. She also had a physician's order, dated 1/16/2022, for Oxycodone 5 mg one tablet (5 mg) by mouth every six hours as needed for severe pain. Review of Resident 371's Controlled Drug Record indicated a licensed nurse removed one-half tablet of Oxycodone 5 mg from Resident 371's supply on 1/19/2022 at 11:00 a.m. A licensed nurse also removed two half tablets of Oxycodone 5 mg from Resident 371's supply on 1/23/2022 at 12:10 p.m. Review of Resident 371's MAR, dated 1/2022, indicated there was no documentation that she received Oxycodone on the above dates and times. Review of Resident 20's medical record indicated he had a physician's order, dated 11/27/2021, for Oxycodone 10 mg by mouth every 4 hours as needed for severe abdominal pain. Review of Resident 20's Controlled Drug Record indicated a licensed nurse removed two tablets of Oxycodone 5 mg from Resident 20's supply on 1/22/2022 at 7:30 a.m. and 11:00 a.m. Review of Resident 20's MAR, dated 1/2022, indicated there was no documentation that he received Oxycodone 10 mg on the above date and times. Review of Resident 66's medical record indicated she had a physician's order, dated 12/30/2021 for Norco 5/325 mg one tablet by mouth every four hours as needed for moderate pain. Review of Resident 66's Controlled Drug Record indicated a licensed nurse removed one tablet of Norco 5/325 mg from Resident 66's supply on 1/17/2022 at 3:00 a.m. Review of Resident 66's MAR, dated 1/2022, indicated there was no documentation that she received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 20 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 Norco/5/325 mg on the above date and time. Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC) on 1/25/2022 at 9:28 a.m., she reviewed the medical records for Residents 31, 371, 20 and 66. The MDSC confirmed there was no documentation that these residents received their controlled medications on the dates and times specified above. The MDSC stated if a licensed nurse removes controlled medications from a resident's supply, they must document on the MAR to show they administered the medication to the resident. Residents Affected - Some The facility's policy titled Preparation and General Guidelines IIA5: Controlled Medications, dated 8/2014 indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record [controlled drug record] and the medication administration record (MAR): 1) Date and time of administration. 2) Amount administered. 3) Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. 4) Initials of the nurse administering the dose on the MAR after the medication is administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 21 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address whether one of 17 sampled residents (Resident 1) would benefit from gradual dose reduction (GDR, stepwise tapering of a dose to determine if conditions can be managed by a lower dose or if the medication can be discontinued altogether) of a psychotropic medication (medication capable of affecting the mind, emotions and behavior). This failure had the potential to result in unnecessary or prolonged use of the psychotropic medication, which could increase the resident's risk of experiencing side effects (undesirable effects from the medication). Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had the diagnosis of dementia (mental disorder caused by brain disease or injury) and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). Review of Resident 1's Order Summary Report indicated she had a physician's order, dated 7/21/2021, for Risperidone (medication used to treat psychotic disorders) 0.5 milligrams (mg, unit of dose measurement) one tablet by mouth one time a day for dementia with psychotic features. Review of Resident 1's Note To Attending Physician/Prescriber, written by the consultant pharmacist (CP) and dated 12/2/2021 indicated, [Resident 1] did not have any behaviors of yelling/screaming out loud and believes that somebody accuse her that she is a thief in the month of November. Per Federal CMS [Centers for Medicare & Medicaid Services] guidelines, gradual psychotropic dose reductions should be attempted in two separate quarters within the first year (with at least one month between attempts) and then annually unless clinically contraindicated. Would a trial discontinuation of the Risperidone be appropriate at this time? If no, please document the risks vs benefits for continued therapy below. During an interview and concurrent record review with the director of nursing (DON) on 1/31/2022 at 9:19 a.m., she stated when the facility receives a Note To Attending Physician/Prescriber from the CP, the attending physician is supposed to indicate if he agrees or disagrees with the recommendations. The DON stated if the attending physician disagrees with a GDR, he is supposed to document a rationale explaining why a GDR will not be attempted. The DON reviewed Resident 1's medical record and confirmed a GDR for Risperidone was not attempted. The DON also confirmed Resident 1's attending physician did not document whether he agreed or disagreed with a GDR, and did not document a rationale for not attempting a GDR for Risperidone. The facility's policy titled General Guidelines for the Use of Psychoactive Medications, revised 10/2012 indicated, Residents who use antipsychotic drugs must receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. Clinically contraindicated (as defined by Centers for Medicare and Medicaid Services [CMS]) means that a resident need not undergo a 'gradual dose reduction' or 'behavioral interventions' if: c. The resident's physician provides a justification why the continued use of the drug and the dose is clinically appropriate . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 22 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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** 2. During review of Resident 38's clinical record, Resident 38 was admitted on [DATE], with diagnoses included dementia (memory loss), major depressive disorder and hypertension (high blood pressure). Review of Resident 38's Minimum Data Set (MDS, an assessment tool), dated 11/18/21, indicated Resident 38 was severely cognitively impaired and required extensive assistance during ADLs. Review of Resident 38 physician's order, dated 10/2021, indicated (1) Risperdal tablet 0.5 mg. Give 1 tablet by mouth one time a day for dementia. (2) Citalopram hydrobromide 20 mg tab. Give 1 tab by mouth OD r/t major depressive disorder. (3) Divalproex sodium cap DR sprinkle 125 mg. Give 4 capsule by mouth BID r/t dementia. There were no target behaviors for use of these antipsychotic/psychotropic medications. During interview with licensed vocational nurse E (LVN E) on 01/28/22 at 1:20 p.m., LVN E acknowledged that the physician order did not specify the target behaviors for use of these medications. LVN E also stated there was lack of behavioral monitoring that were specific for the use of each of these medications. 3. During record review of Resident 47's clinical record, Resident 47 was admitted on [DATE] with diagnoses including dementia, hypertension and major depressive disorder. Review of Resident 47's physician order, dated 9/2/21, indicated: (1) Seroquel 25 mg tab. Give 3 tablet by mouth at HS for Alzheimer's r/t dementia .(2) Mirtazapine 7.5 mg tab. Give 2 tablet by mouth at bedtime for sleep and appetite r/t major depressive d/o. There were no specific target behaviors for use of these psychotropic medications. During an interview with LVN E on 01/28/22 at 1:45 PM , LVN E acknowledged there was no behavior monitoring specified, and stated there should have been target behaviors specified for the use of each of the medications. During an interview with the director of staff development (DSD) on 1/28/22 at 1:22 pm, the DSD acknowledged the above findings and stated that monitoring target behaviors for use of these medications were important parameters to measure the effectiveness of the use of these antipsychotic/psychotropic medications. Based on interview and record review, the facility failed to ensure three of 17 sampled residents (Residents 43, 38 and 47) were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions and behavior) when: 1. For Resident 43, the facility did not identify and monitor target behaviors (specific behaviors intended to be reduced or eliminated by the medication), did not monitor side effects (undesirable effects from the medication), and did not identify appropriate indications for the use of psychotropic medications; 2. For Resident 38, the facility did not identify and monitor target behaviors for psychotropic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 23 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 medications; and Level of Harm - Minimal harm or potential for actual harm 3. For Resident 47, the facility did not identify and monitor target behaviors for psychotropic medications. Residents Affected - Few These failures compromised the facility's ability to determine whether or not the psychotropic medications were effective. These failures also increased the residents' risk of experiencing harmful effects from the psychotropic medications. Findings: 1. Review of Resident 43's medical record indicated she was admitted on [DATE] and had the diagnoses of bipolar disorder (a mental health condition that causes extreme mood swings) and major depressive disorder (a mood disorder that causes persistent feelings of sadness or loss of interest). Review of Resident 43's Order Summary Report indicated she had a physician's order, dated 12/1/2021, for Sertraline (medication used to treat depression) 100 milligrams (mg, unit of dose measurement) one tablet by mouth one time a day for antidepressant. She also had a physician's order, dated 12/1/2021, for Quetiapine (medication used to treat psychotic disorders) 25 mg one tablet by mouth one time a day for anxiety. The physician's orders did not specify target behaviors for Sertraline or Quetiapine. Review of Resident 43's medication administration record (MAR), dated 12/2021 and 1/2022, indicated there was no documentation of behavior monitoring or side effects monitoring for Sertraline or Quetiapine. During an interview with registered nurse D (RN D) on 1/26/2022 at 1:38 p.m., she confirmed the facility must identify target behaviors for residents receiving psychotropic medications. RN D stated nurses should monitor the residents for target behaviors and side effects and document this on the MAR. RN D reviewed Resident 43's medical record and confirmed there was no documentation of behavior monitoring and side effects monitoring for Sertraline or Quetiapine. During an interview with the unit manager (UM) on 1/26/2022 at 2:01 p.m., she confirmed antipsychotic medications needed to have appropriate indications for use. The UM reviewed Resident 43's medical record and confirmed anxiety was not an appropriate indication for use of Quetiapine. During an interview with the consultant pharmacist (CP) on 1/31/2022 at 8:30 a.m., he confirmed behavior monitoring, side effects monitoring, and appropriate indications for use must all be in place for residents receiving psychotropic medications. The CP reviewed his own records and confirmed Resident 43 was missing behavior and side effects monitoring for Sertraline and Quetiapine. The CP also acknowledged anxiety was not an appropriate indication for the use of Quetiapine. The facility's policy titled General Guidelines for the Use of Psychoactive Medications, revised 10/2017 indicated, Designated facility staff will document episodes of behavior, the impact of the medication on behavior, and the presence or absence of side effects. The policy further indicated antipsychotic medications should not be used if anxiety is the only indication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 24 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and facility document review, the facility failed to ensure residents were provided a well-balanced diet that met nutrition needs when serving sizes on the meal tray tickets did not match the planned and approved menu for Regular diets, Regular Puree diets (texture modified diets that do not require chewing), Carbohydrate Controlled (CCHO, therapeutic diets designed for people with diabetes to keep the carbohydrate levels in meals evenly spaced throughout the day), Mechanical Soft diets (texture modified diets that require less chewing than regular diets), and Renal 80 gram (therapeutic diet that is low in sodium, phosphorus, and protein for people with kidney disease) CCHO Mechanical Soft diets. This failure had the potential to result in not meeting the nutritional needs thus further compromising the medical status of 32 out of 68 residents eating in the facility. Findings: Review of facility document titled Winter Menu (spreadsheet), dated 12/27/21 - 2/27/22, indicated for 1/24/22 Monday Lunch, the serving sizes for the Regular diet were: one Beef Enchilada, #12 (1/3 cup) scoop of Black beans, and #12 scoop (1/3 cup) of Cilantro Lime Rice. During an observation of the lunch meal service on 1/24/22 starting at 11:42 a.m., food service worker C (FSW C) served two Beef Enchiladas, a #8 scoop (½ cup) of Black Beans, and a #12 scoop (1/3 cup) of Cilantro Lime [NAME] for each Regular diet resident plate. FSW C and Dietary Services Supervisor (DSS) confirmed all Regular diets got two enchiladas, a #8 scoop (1/2 cup) black beans, and a #12 scoop (1/3 cup) of rice. Review of the lunch meal tray tickets from 1/24/22 for Residents 66 and 271 indicated Regular and serving sizes were: two Beef Enchiladas, ½ cup Black Beans, and 1/3 cup Cilantro Lime Rice. Review of facility provided document titled (Facility Name) Census List dated 1/24/22 indicated 18 residents (Residents #66, 271, 47, 52, 12, 36, 31, 23, 269, 10, 58, 8, 16, 57, 51, 45, 369, 268) received Regular diets for lunch that day. A random review of four more lunch meal tray tickets from 1/24/22 found the following differences in serving sizes when compared to the 1/24/22 Lunch Winter menu spreadsheet serving sizes for those diets: 1. Regular Pureed diet (Resident 43): Black beans #8 (1/2 cup) scoop instead of #12 (1/3 cup) scoop, 2. CCHO Mechanical Soft (Resident 270): Soft black Beans #12 (1/3 cup) scoop instead of #16 (1/4 cup) scoop and Soft Cilantro Lime [NAME] #12 (1/3 cup) scoop instead of #16 (1/4 cup) scoop, 3. Renal 80 gram CCHO Mechanical Soft (Resident 44): Seasoned Ground Beef w/ Gravy on Bun 2 oz instead of 3 oz; Creamed Corn 1/4 cup instead of #8 (1/2 cup); and Soft Cilantro Lime [NAME] #16 (1/4 cup) instead of #12 (1/3 cup), and 4. Renal 80 gram CCHO (Resident 42): Seasoned Ground Beef with Gravy on Bun 6 oz (Ounces) instead (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 25 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0800 of 3 oz. Level of Harm - Minimal harm or potential for actual harm Review of facility provided document titled (Facility Name) Census List dated 1/24/22 indicated three residents (Residents 32, 43, 35) received Regular Pureed diets for lunch that day. Residents Affected - Some Review of facility provided document titled (Facility Name) Census List dated 1/24/22 indicated eight residents (Residents 19, 11, 270, 28, 34, 37,17, 9) received CCHO Mechanical Soft diets for lunch that day. Review of facility provided document titled (Facility Name) Census List dated 1/24/22 indicated 2 residents (Residents 22, 44) received Renal 80 gm CCHO Mechanical Soft diets for lunch that day. Review of facility provided document titled (Facility Name) Census List dated 1/24/22 indicated one resident (Resident 42) received Renal 80 gm CCHO diet for lunch that day. During an interview on 1/24/22 at 12:35 p.m. with dietary services supervisor (DSS) and food service worker C (FSW C), DSS and FSW C confirmed they used the serving sizes indicated on the meal tray tickets to serve the meals to residents. DSS further confirmed that some of the meal tray tickets serving sizes did not match the menu spreadsheet serving sizes and was unsure why they did not match. DSS stated she will check with the corporate Registered Dietitian and that she had not noticed these discrepancies before the surveyor pointed them out. During an interview on 1/25/22 at 8:40 a.m. with Registered Dietitian A (RD A) in the presence of DSS, RD A confirmed meal tray tickets serving sizes should match the menu spreadsheet serving sizes. RD A stated the nutrient analysis of the menus is based on the menu spreadsheet serving sizes which are based on the recipes. RD A stated she would look into why the serving sizes are not matching between the meal tray tickets and the menu spreadsheet. During an interview on 1/25/22 starting at 10:23 a.m., RD A stated the corporate dietary services supervisor (CDSS) made corrections to serving sizes on the meal tray tickets that morning and now the serving sizes match the menu spreadsheet for the week. RD A stated she worked with CDSS on a conference call that morning to fix the differences in serving sizes between the meal tray tickets and menu spreadsheet. RD A further stated there were changes made, similar to the serving sizes found by the surveyor, on every day except Friday. RD A stated she assumed CDSS would correct the rest of the weeks of the menu cycle, but she was not sure. RD A stated CDSS's job is to enter the serving sizes into the meal tray ticket system to match the menu spreadsheet. During an interview on 1/25/22 at 10:33 a.m., DSS stated the previous registered dietitian (RD B) used to observe the meal service every day, would verbally give feedback to DSS, and had not noted the discrepancies in serving sizes. She also stated RD B's last day was 1/14/22. The most recent Registered Dietitian audit forms were requested. Review of facility documents titled Sanitation Audit Report dated 11/2021, 9/2021, 8/2021, and 7/2021, indicated the registered dietitian did not identify any issues under Food items served match what is listed on tray ticket. One issue was identified in 11/2021 under Menus and recipes followed and a handwritten note said, Follow diet spreadsheet see comment. The handwritten comment said one meal at Lunch did not follow CCHO diet dessert, instead diet (sugar-free) ice cream and provide sherbet. Followed dietary staff and manager and in-service the importance of following diet spreadsheet. No issues with serving sizes were identified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 26 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During a telephone interview on 1/26/22 at 1:06 p.m., RD A confirmed the serving size differences found between what was being served and what was on the menu would affect the nutrient analysis. Review of facility document titled Menu Planning, dated 2020, indicated The menus are planned to meet the nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances .Menus are to be approved by the facility Registered Dietitian prior to the beginning of each quarterly menu cycle. Event ID: Facility ID: 555635 If continuation sheet Page 27 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when: Residents Affected - Many 1. Food service equipment was stored wet, and 2. The floor below the dish machine was not smooth and cleanable. These failures had the potential to cause the growth of microorganisms or attract pests which could cause foodborne illness or cross-contaminate food (cross-contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the 68 residents eating at the facility. Findings: 1. During the initial kitchen tour on 1/24/22 starting at 8:55 a.m., the following was found on a storage rack in the middle of the kitchen: Three four-quart plastic containers were wet inside and stacked together, one twelve-quart plastic container was wet inside and stacked with other similar containers, one large plastic bowl was wet inside and stacked with similar items, and five metal pans were wet inside and stacked together. During an interview at that time with the dietary services supervisor (DSS), DSS confirmed all equipment was wet and should have been air dried before stacking and storing. DSS stated this is all the space they have for air drying, indicating the storage rack that the wet, stacked pans and containers were on. On another observation in the kitchen on 1/24/22 starting at 2:15 p.m., sixteen coffee mugs were observed wet inside and inverted (upside down) directly on trays. In an interview at that time with food service worker A (FSW A) and food service worker B (FSW B), they confirmed the mugs were wet inside and should have been air dried before storing upside down on trays. Review of facility policy titled Dish Washing, dated 2018, indicated Dishes are to be air dried in racks before stacking and storing. According to the 2017 Food and Drug Administration (FDA) Food Code, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: shall be air-dried . According to the FDA Food Code 2017 Annex 4-901.11 items must be allowed to drain and to air-dry before being stacked or stored. 2. During an observation on 1/24/22 at 2:30 p.m. in the kitchen, an approximately ten by four foot area of concrete flooring directly beneath the dish machine between the dirty and clean side had cracks and a rough, bumpy, and crumbly texture. During an interview at that time, DSS confirmed the floor under the dish machine was rough with cracks and was not smooth. DSS stated the facility had replaced floors throughout the building and planned to replace or redo the floor in kitchen. DSS further confirmed that this section of flooring is hard to clean, and that staff can sweep it, but they cannot mop it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 28 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 Residents Affected - Many During an interview on 1/25/22 at 10:51 a.m. with the administrator (ADM), ADM stated he is aware of the rough floor under the dish machine, and they plan to make fixes to the floor in kitchen. He further stated the maintenance supervisor (MS) is a contractor, so he talked to him several times about fixing the floor. ADM provided documentation showing a quote for flooring replacement throughout the facility except the kitchen. During an interview on 1/25/22 at 12:19 p.m. with MS regarding the rough floor under the dish machine, MS stated he is aware of the issue and the plan is to tile under there so the kitchen staff can clean it. He further stated if they just paint over it again, it will be same problem where the paint will flake off and expose the rough floor. MS did not know when they would do the tiling and that he had not yet ordered or purchased the tiles. During a telephone interview on 1/26/22 starting at 11:32 a.m. with registered dietitian (RD A), RD A confirmed the floor under dish machine should be cleanable and smooth. Review of facility document titled General Appearance of Food and Nutrition Department, dated 2018, indicated Floors .must be scheduled for routine cleaning and maintained in good condition, and Floors must be mopped at least once per day. According to the 2017 Food and Drug Administration (FDA) Food Code, Section 6-201.11 Floors, Walls, and Ceilings, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. In the 2017 FDA Food Code in section 1-2 Definitions Smooth means: .(3) A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 29 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to obtain consents to either receive or refuse pneumonia vaccine for one of five residents (Resident 23). This failure put the resident at risk of not being informed of the risks and benefits of the pneumonia vaccines, and not giving them the ability to make an informed decision. Residents Affected - Few Findings: Review of Resident 23's electronic record (eRecord) for vaccine status, the eRecord indicated a consent was needed for pneumovax (a pneumonia vaccine). Neither a consent nor refusal was located by the surveyor. During an interview on 1/28/22 at 10:21 a.m. with the Infection Preventionist (IP), IP stated she had not found a consent to accept or refuse the pneumovax vaccine for Resident 23. During a review of the facility's policy and procedure (P&P) titled, Pneumococcal Vaccination, revised 05/2009, the P&P indicated, .1. Upon admission the resident will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, provided the vaccination within sixty (60) days of admission to the facility unless medically contraindicated or the resident refuses the vaccine for personal or religious reasons.5. Administration of vaccine/ immunization is recorded in the resident's clinical record. The date of vaccination, lot number, expiration date, person administering the vaccine and the site of the vaccination will be recorded in the clinical record . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 30 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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 0885 Report COVID19 data to residents and families. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to notify all residents, their representatives, and families of a confirmed case of COVID-19 in the facility in a timely manner, when the communication was not sent for five days after a positive COVID-19 case was identified in the facility. This failure could potentially cause a spread of COVID-19 in the facility and is in violation of federal regulations to mitigate the spread of COVID-19 virus. Residents Affected - Some Findings: During an interview on 1/28/22 at 2:14 p.m. with the Infection Preventionist (IP), IP stated she had first learned of a resident having a positive COVID-19 test on 1/8/22. During an interview on 1/31/22 at 9:10 a.m. with the administrator (ADM), ADM stated he used text them all service to notify families. ADM stated this was done on 1/13/22. ADM stated he was first aware of a positive COVID-19 case on 1/8/22. During a review of the facility's Mitigation Plan, it indicated, .Facilities must inform residents and their representatives by 5:00 PM the day after an occurrence of a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms that occur within 72 hours.Also, updates to residents and their representatives with cumulative information must be provided weekly. or each subsequent time a confirmed infection of COVID-19 is identified . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 31 of 32 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 555635 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/31/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Courtyard Care Center 340 Northlake Drive San Jose, CA 95117 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the failed to maintain comfortable and sanitary shared bathroom for one of three residents, when there was a black matter and long, narrow piece of black material that was sticky on one side in the bathroom tile surfaces. Also, the two tissue holder beside the toilet had no rollers. This had the potential to affect resident's psychosocial well-being. Findings: During observation on 01/26/22 at 10:15 a.m., in the bathroom commonly shared by Residents 9, 53 and 55, there was a black matter and long, narrow piece of black material that was sticky on one side in the bathroom tile surfaces. The door was hard to open because it was stuck. Also, the two tissue holder had no rollers beside the toilet. During an interview with Resident 55 on 01/26/22 at 10:30 a.m., Resident 55 stated it felt awful to look it that way. Resident 55 stated that housekeepers did not clean daily. During an interview with registered nurse F (RN F) on 01/26/22 at 10:35 a.m., RN F acknowledged the above findings and stated it should be cleaned with bleach to remove the black matter, and the housekeeper should ensure the tissue holders were fixed to hold tissue rolls. The facility's undated policy and procedure titled Complete Room Cleaning, indicated .4. Dust mop floor. Use [NAME] mop to gather all trash & debris on floor 5. Damp mop floor with germicide solution damp mop floor working from back corner to door. Use Wet Floor sign when finished . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 32 of 32