Health inspection·October 6, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure activities of daily living (ADL) were provided to maintain good grooming and personal hygiene for one of 17 sampled residents (Resident 46) when Resident 46's fingernails were unkept. This failure left the resident incompletely groomed. Residents Affected - Few Findings: Review of Resident 46's clinical record indicated she had the diagnoses of dementia (conditions characterized by impairment of least two brain functions, such as memory loss and judgement), and muscles weakness. During a concurrent observation and interview with the Certified Nursing Assistant (CNA) B in Resident 46's room on 10/4/23 at 9:06 a.m., resident's fingernails were long with black matter underneath the nails. CNA B confirmed this observation and stated the nails should be cleaned during ADL care. During an interview with Resident 46's responsible party (RP, person designated to make decisions on behalf of a resident) on 10/5/23 at 11:32 a.m., she stated she spoke with facility staff a month ago regarding Resident 46's nail care not being done. During an interview with the Director of Staff Development (DSD)/Interim Infection Preventionist (IIP) on 10/05/23 at 8:27 a.m. , she stated nailcare should be done on shower days; and that, Resident 46's shower schedule was twice a week. During an interview with the Director of Nursing (DON) on 10/6/23 at 1:46 p.m., she stated residents' nails should be cleaned during shower days by CNAs. Review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL),dated 12/19/22, indicated, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 2 of 11 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 10/06/2023 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 Based on observation, interview, and record review, the facility failed to maintain professional standards of practice for one of four sampled residents (Resident 28) when oxygen was not administered per a physician's order. This failure resulted in Resident 28 receiving oxygen at a higher setting than prescribed. Residents Affected - Few Findings: During an observation 10/2/23 at 9:32 a.m. in Resident 28's room, the resident was observed receiving oxygen at 5 liters (L, a metric unit of volume) via nasal cannula (NC, a flexible tubing placed into the nostrils and connected to an oxygen source). During an interview and record review with licensed vocational nurse (LVN) G on 10/04/23 at 8:56 a.m., Resident 28's oxygen order, dated 1/27/23, indicated 2 L via NC as needed for shortness of breath. LVN G confirmed Resident 28 was on 5 L oxygen, while the physician's order for 2 L oxygen was not followed. During an interview with the director of nursing (DON) on 10/6/23 at 1:46 p.m., she stated nursing staff should follow physicians' orders when administering medications or oxygen. Review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 12/19/2022, indicated, Oxygen is administered under orders of a physician, except in the case of an emergency. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 3 of 11 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 10/06/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. During an observation 10/2/23 at 8:49 a.m., Residents 36, 43 and 56 were in their beds with quarter side rails up. Review for Resident 36's Bed Rails assessments lacked documented evidence that Resident 36 was assessed for bed rails safety between 4/27/21 and 10/2/23. Review for Resident 43's Bed Rails assessments lacked documented evidence that Resident 43 was assessed for bed rails safety between 4/29/21 and 10/2/23. Review for Resident 56's Bed Rails assessments lacked evidence that Resident 56 was assessed for bed rails safety. Based on observation, interview, and record review, the facility failed to assess bed rails (adjustable metal or rigid plastic bars that attach to the bed) safety for 12 of 17 residents (Residents 6, 11, 12, 21, 26, 28, 36, 43, 46, 52, 54 and 56) periodically, according to their policy. This failure placed the residents at risk for entrapment and injury. Findings: During the initial tour of the facility conducted on 10/2/23, at 9:00 a.m., Residents 12, 52, and 54, all had quarter bed rails elevated. Review for Resident 12's Bed Rails assessments lacked evidence to indicate Resident 12 was assessed for bed rails safety between 1/30/23 and 10/6/23. Review for Resident 52's Bed Rails assessments lacked evidence to indicate Resident 52 was assessed for bed rails safety between 5/30/22 and 10/6/23. Review for Resident 54's Bed Rails assessments lacked evidence to indicate Resident 54 was assessed for bed rails safety between 6/3/22 and 8/24/23. During the initial tour of the facility conducted on 10/2/23, at 9:32 a.m., Residents 6, 11, 21, 26, 28, and 46 all had quarter bed rails elevated. Review for Resident 6's Bed Rails assessments lacked evidence Resident 6 was assessed for bed rails safety between 4/19/22 and 10/6/23. Review for Resident 11's Bed Rails assessments lacked evidence Resident 11 was assessed for bed rails safety between 7/11/22 and 10/6/23. Review for Resident 21's Bed Rails assessments lacked evidence Resident 21 was assessed for bed rails safety between 11/28/22 and 10/6/23. Review for Resident 26's Bed Rails assessments lacked evidence Resident 26 was assessed for bed rails safety between 10/5/22 and 10/6/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 4 of 11 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 10/06/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Review for Resident 28's Bed Rails assessments lacked evidence Resident 28 was assessed for bed rails safety between 10/21/22 and 10/6/23. Review for Resident 46's Bed Rails assessments lacked evidence Resident 46 was assessed for bed rails safety between 9/10/22 and 10/6/23. Residents Affected - Some During an interview with the Director of Nursing (DON) on 10/5/23 at 1:15 p.m., she stated bed rails assessments were to be done upon admission and re-evaluated every quarter. Review of the facility's policy and procedure (P&P) titled Proper Use of Bed Rails, reviewed/revised 12/19/2022, indicated, Responsibilities of ongoing monitoring and supervision are specified as follows: b. A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly upon a significant change in status, or a change in the type of bed/mattress/rail. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 5 of 11 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 10/06/2023 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 ensure medications from one of three emergency kits (e-kits) were locked and replaced after use. Residents Affected - Few This failure had the potential to result in medications not being available during emergency situations. Findings: During a concurrent observation and interview in the medication storage room with Registered Nurse (RN) D on 10/2/23 at 11:02 a.m., the e-kit containing injectable medications (administered with a needle and syringe) was found unlocked. RN D stated e-kits should be locked and restocked within 24 to 48 hours, so medications are available for residents. During concurrent interview and record review with RN D on 10/2/23 at 11:02 a.m., the e-kit pharmacy log indicated Ertapenem, an intravenous (within a vein) antibiotic used to treat infections, was removed 9/18/23. RN D confirmed the e-kit was open at that time but not relocked or restocked. During an interview with the Director of Nursing (DON) on 10/4/23 at 3:40 p.m., she confirmed the e-kit should be locked and replaced. Review of the facility's policy Emergency Pharmacy Service and Emergency Kits, dated August 2014, indicated, When an emergency or stat (immediate) dose of a medication is needed, the nurse unlocks the container and removes the required medication. After removing the medication, complete the emergency e-kit slip and re-seal the emergency supply. As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the emergency drug supply. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 6 of 11 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 10/06/2023 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility had a 5.13% (percent, a specified amount of units for every hundred units) medication error rate when two medication errors out of 39 opportunities were identified during medication pass for two of ten residents (Resident 2 and Resident 220). Residents Affected - Few These failures had the potential to result in ineffective drug therapy. Findings: Review of Resident 2's clinical record. An Order Summary Report, dated 10/4/23, indicated Lidocaine External Patch 4% (Lidocaine patches are generally used to help relieve pain) Apply to generalized painful areas topically (on the skin) one time a day for generalized pain. Apply to the area resident requests. Start date 2/22/23. Teview of Resident 220's clinical record titled, Order Summary Report, dated 10/4/23, indicated, Propranolol HCL (Propranolol HCL, medication used to treat high blood pressure) oral tablet 10 mg (milligrams, a unit of measure)(BP -the pressure of circulating blood against the walls of blood vessels) Give 1 tablet by mouth two times a day for HTN (hypertension - elevated blood pressure). Hold for SBP <100 (systolic blood pressure, the bottom number of a blood pressure reading). Start date 9/18/23. During a medication administration observation on 10/3/23 at 7:47 a.m., the Licensed Vocational Nurse (LVN) C prepared medications for Resident 2. During a medication administration observation and concurrent interview with LVN C on 10/3/23 at 8:33 a.m., LVN C prepared medications for Resident 220. LVN C stated Propranolol was not available and needed to be ordered. During a follow up interview with LVN C on 10/3/23 at 3:08 p.m., LVN C stated the propranolol for Resident 220 arrived, but had not been given during and since the morning medication administration pass. LVN C also stated Resident 2's lidocaine patch scheduled for morning administration was not given. Review of the facility's policy titled Medication Administration, dated 12/19/23, indicated, b. Administer [medications] within 60 minutes prior to or after scheduled time unless otherwise ordered by Physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 7 of 11 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 10/06/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to follow their policy for medication self-administration for 1 of 3 residents (Resident 25) when Resident 25 had medications on her bedside table without an IDT (interdisciplinary team, composed of a group of healthcare staff from various disciplines who work together to discuss care for individual residents) evaluation allowing for it. This failure left medications accessible to a resident, who lacked an evaluation for whether such medications should be left at her bedside. Findings: During an observation on 10/3/23 at 9:40 a.m., there was a bottle of Pepto-Bismol and Ibuprofen 200 mg tablets on the bedside table of Resident 25. During a concurrent interview with Resident 25, Resident 25 stated, I take the medication when needed, but not often. During an observation on 10/5/23 at 8:19 a.m., there was an albuterol inhaler (inhalable medication used to improve breathing) on the bedside table of Resident 25. During a concurrent interview with Resident 25, she stated she sent home the Pepto-Bismol and Ibuprofen because she was not using them very often; and now, she has the albuterol inhaler. During an interview on 10/5/23 at 8:19 a.m. with LVN F, LVN F stated she was not aware Resident 25 had medications at her bedside for self-administration. Review of Resident 25's clinical record, dated October 2023, lacked evidence of any evaluation, order, or care plan for medication self-administration. During an interview with the Director of Nursing (DON) on 10/5/23 at 3:25 p.m., she stated for self-administered medications, an assessment on the resident is completed, an order is obtained from the physician, and a care plan is created. The DON stated none of these three steps were taken for Resident 25 and she was unaware of medications unattended by staff at the resident's bedside. Review of the facility's policy titled, Medication Administration, dated 12/19/22, indicated, .Observe resident consumption of medications. Review of the facility's policy titled, Resident Self- Administration of Medication, dated 12/19/22, indicated, It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 8 of 11 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 10/06/2023 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 record review, the facility failed to ensure food was stored in accordance with professional standards for food safety when: Residents Affected - Some 1. A dented can of applesauce was stored on a the dry storage shelf. 2. An outdated bag of pinto beans was stored on a dry storage shelf. 3. Outdated onions were stored on a dry storage shelf; and, 4. Outdated ground herbs were stored on top of the kitchen condiment shelf. These failures had the potential to cause foodborne illness for residents who received food from the kitchen. Finding: 1. During a concurrent kitchen observation and interview with the Registered Dietician (RD) on 10/02/23 at 9:11 a.m., a dented can of unsweetened applesauce was on a shelf in the dry storage area intended for items to be consumed. The RD confirmed this observation and stated dented cans should be stored in an area designated for dented cans. Review of the facility's policy and procedure titled, Food Storage, revised 8/29/23, indicated, dented or bulging cans should be placed on Damaged Goods Shelf and returned for credits. 2. During a concurrent kitchen observation and interview with the RD on 10/02/23 at 9:11 a.m., a plastic bag of pinto beans with an open date of 8/25/23 and use by date of 9/25/23 written on the bag was on a dry storage shelf. The RD stated the pinto beans should should have been removed. 3. During a concurrent kitchen observation and interview with the RD on 10/02/23 at 9:11 a.m., a plastic container was filled with red and yellow onions that were soft to the touch. The container had a label that indicated, 9/18/23 yellow, red onion, UB [use by]: 9/26/23. The RD confirmed the onions had passed their use by date. During an interview with the Dietary Manager (DM) on 10/5/23 at 10:38 a.m., she stated food items should be disposed of by the use by date. 4. During a concurrent kitchen observation and interview with the DM on 10/2/23 at 2:00 p.m., a bottle of expired Mediterranean-style ground oregano had a label that indicated, opened 9/2/22 use by 9/2/23. The DM stated it should not be there for use. Review of the facility's P&P titled, Food Storage - Dry Storage, revised 8/9/23, indicated, Any expired or outdated food products should be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 9 of 11 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 10/06/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: Residents Affected - Some 1. Certified Nursing Assistant (CNA) B did not remove their gloves or perform hand hygiene after placing dirty laundry in a bin before taking a wheelchair into a room; and, 2. Licensed Vocational Nurse (LVN) C did not clean a blood pressure (BP) cuff after obtaining vital signs for 4 of 4 residents (Residents 2, 46, 63, and 220) during medication pass. These failures increased the potential for the spread of communicable diseases among residents. Findings: 1. During an observation on 10/2/23 at 9:26 AM, CNA B, walked to the hallway from room [ROOM NUMBER] wearing gloves and carrying a full linen bag. CNA B placed the linen bag in the dirty linen bin and, without removing the gloves worn, took a clean wheelchair from the hallway into room [ROOM NUMBER]. During an interview with CNA B on 10/2/23 at 9:48 AM, he confirmed he took the wheelchair into room [ROOM NUMBER] without changing his gloves or cleaning his hands after placing the dirty laundry in the bin. CNA B stated he should have removed his gloves and cleaned his hands after disposing of the laundry before moving the wheelchair. Review of the facility's policy Hand Hygiene, dated 12/19/2022, indicated, 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . Before and after handling clean or soiled dressings, linens . 2. During an observation on 10/3/23 at 7:47 a.m., LVN C took Resident 2's blood pressures (BP) prior to giving medications, then continued passing medications. LVN C then took Resident 46, Residents 220, and Resident 63's BP during the medication pass. LVN C did not clean/disinfect the BP cuff and/or before or after use. During an interview with LVN C on 10/3/23 at 9:15 a.m., he confirmed he did not clean the BP cuff and machine after using it for the Residents 2, 46, 220, and 63; and that, he should have cleaned it with disinfectant wipes after each use. Review of the facility's policy Infection Prevention and Control Program, dated 9/2/2022, indicated, All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 10 of 11 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 10/06/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer the correct pneumococcal vaccine (vaccine to prevent bacterial pneumonia [infection of the lungs]) for one of five sampled residents (Resident 25) per the Centers for Disease Control and Prevention (CDC)'s pneumococcal vaccine schedule guidelines. This failure resulted in Resident 25 receiving an additional unnecessary pneumococcal vaccine. Residents Affected - Few Findings: Review of Resident 25's facesheet (a document that gives a resident's information at a quick glance, including contact details and a brief medical history), indicated Resident 25's date of birth was 8/5/1956, and she was admitted on [DATE]. During a concurrent interview and record review with the director of staff development (DSD)/interim infection preventionist (IIP) on 10/05/23 at 01:57 p.m., Resident 25's Immunization Report, dated 10/5/23, indicated Resident 25 received pneumovax 23 (PPSV23, a type of pneumococcal vaccine) on 3/27/17 and 4/7/23. The DSD/IIP stated, per CDC new pneumococcal vaccination guidelines, Resident 25 should have received Prevnar 20 (PCV20, a type of pneumococcal vaccine) instead of PPSV23. During an interview with the director of nursing (DON) on 10/06/23 12:47 p.m., she stated the facility provided new guidelines for pneumococcal vaccination to staff and the new vaccines were ordered and provided by the pharmacy; such that, Resident 25 should have received PCV20 per the new guidelines. Review of the facility's policy and procedure titled Pneumococcal Vaccine (Series), reviewed/revised 9/2/22, indicated, A pneumococcal vaccination is recommended for all adults 65 years and older and based on the following recommendations: a. For adults 65 years' or older who have only received a PPSV23: Give 1 dose PCV15 or PCV20. [ .] ii. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 11 of 11