Health inspection·January 31, 2025

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of Resident 70's clinical record indicated Resident 70 was admitted on [DATE] with diagnoses of deconditioning and schizoaffective disorder (a disorder of the brain that can cause people to see and hear things that are not real). Review of Resident 70's clinical record indicated Resident 70 had an order for Olanzapine (medication used to treat schizophrenia) 2.5 mg by mouth daily for schizoaffective disorder. Review of Resident 23's clinical record further indicated an informed consent was signed on 12/29/24 by the responsible party. The risks, benefits, and side effects of the medication were not listed in the informed consent form. During an interview with the IDON on 1/30/25 at 2:56 p.m, the IDON said the consent that was in the chart for Resident 70 for Olanzapine was the current consent being used. 3. Review of Resident 34's clinical record indicated Resident 34 was admitted on [DATE] with a diagnosis including hypoxic brain injury (an injury caused by lack of oxygen). Review of Resident 34's clinical record also indicated he had a chest X-ray ordered and completed on 1/10/25 which indicated the lungs were clear. Review of Resident 34's clinical record further indicated that there was no record of a note stating the responsible party was contacted about the results of the chest X-ray. During an interview with the IDON on 1/30/25 at 4:26 p.m., the IDON stated it was unclear whether the chest X-ray result was communicated to Resident 34's responsible party after the results were received by the facility. Review of facility policy titled Notification of Changes, dated 12/19/22, indicated .The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include .Significant change in the resident's physical, mental or psychosocial condition .Circumstances that require a need to alter treatment. This may include .New treatment . 4. A review of Resident 174's medical records indicated diagnoses of but are not limited to, anxiety disorder (mental health conditions that involve excessive fear, worry, or panic), major depressive disorder (persistent feelings of sadness, hopelessness, and lack of interest in activities), and paranoid schizophrenia (a condition typically affects your thinking abilities, memories, and senses). During a concurrent interview and record review of Resident 174's medical records with the IDON on 1/30/25 at 11:20 a.m., the IDON verified that Resident 174 was on Risperidone, Buspirone (anxiolytic, used to treat symptoms of anxiety, such as fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress) and Sertraline (antidepressant, used to treat symptoms of depression) medications. The IDON verified and stated that the informed consent they used for psychotropic medication titled, Physician Documentation of Informed Consent. The IDON verified the consent form indicated, PHYSICIAN USE ONLY and there was no space indicated for a signature from a resident or a representative giving the consent. The IDON also verified Resident 174's consent forms for medications Risperidone, Buspirone, and Sertraline dated 8/17/23 did not indicate specific frequency, indications, possible side effects and adverse reactions of each medication, no signature from Resident 174 and no indication if consent was verbal. The IDON verified the facility form titled, Facility Verification of Informed Consent for Resident 174's medications Risperidone, Buspirone, and Sertraline did not indicate a date and signature from Resident 174 or a representative. The IDON also verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 2 of 20 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 01/31/2025 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 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 174's consent forms titled, Psychoactive Medication Consent dated 8/20/21 for medications Risperidone, Buspirone and Sertraline indicated the classifications of the medications (anti-psychotic, anti-anxiety, and anti-depressant), the specific frequency and indications of each medications, side effects and adverse reactions, and Resident 174's signature. The IDON verified the form titled, Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or 'Prolonged Use of Active' Device for Resident 174's Risperidone, Buspirone, and Sertraline dated 8/20/21 indicated signature from a facility staff. The IDON stated that the facility changed its consent forms since a new company took over. A review of Resident 174's Physician Orders indicated the following: - Risperidone Oral Tablet Disintegrating 1 mg [milligram, unit of measurement]; give 0.5 tablet by mouth two times a day for paranoia related to paranoid schizophrenia - Buspirone HCl tablet 10 mg; give 1 tablet by mouth one time a day m/b [manifested by] excessive worrying related to major depressive disorder - Sertraline HCl Oral tablet 50 mg; give 1 tablet by mouth one time a day for m/b expression of sadness over medical condition related to major depressive disorder A review of facility's policy and procedure (P&P) titled, Informed Consent revised 3/25/24, the P&P indicated, Policy Explanation and Compliance Guidelines: 2. Psychotherapeutic Medications: a. The information provided to the resident/health care decision maker regarding a decision concerning the administration of psychotherapeutic medication . i. The reason for the treatment and the name and nature and seriousness of resident's illness. Ii. The nature of the medication to be used including the does, frequency, duration . vi. That the resident has the right to accept or refuse the proposed medications .and if he or she consents, has the right to revoke his or her consent for any reason at any time. b. Prior to initiating the administration of a psychotherapeutic medication .licensed nursing staff shall verify with the resident or surrogate decision maker that he/she has given informed consent for the proposed psychotherapeutic medication .to the prescriber. Psychotherapeutic medications may not be administered until informed consent has been verified. 3. If a form is used to document that informed consent was verified, the licensed nursing staff will complete the Verification of Informed Consent Form and place it under the consent section in the clinical record. 4. The physician may document that he/she obtained informed consent in the clinical record, on progress notes, history and physical or a standard form used by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 3 of 20 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 01/31/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney that authorizes another person to act on behalf of the resident) and completion of the Physician Order for Life-Sustaining Treatment (POLST, a document that specifies the medical treatments the residents wants to receive during serious illness) form for one out of two sampled residents (Resident 23). These failures had the potential to lead to the delivery of unnecessary or inappropriate medical services against residents' goals and wishes. Findings: Review of Resident 23's admission record indicated Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's POLST form dated 1/20/24 indicated section D for AD was marked for Advance Directive, Healthcare Agent if named in Advance Directive field was empty. Further review of Resident 23's clinical record indicated there was no documented copy of an AD signed by the resident or responsible party (RP, a person who is accountable for making decisions on behalf of the resident). During a concurrent interview and record review on 1/30/25 at 11:09 a.m., with the social services director (SSD), the SSD confirmed that Resident 23's POLST form was marked for Advance Directive but that she would need to follow up to see if there was a copy on file. Review of the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives, dated 12/19/22, indicated .Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 4 of 20 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 01/31/2025 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to ensure the Long Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) was notified in writing of a transfer for 82 transfers/discharges. This failure had the potential of not providing 71 residents and/or their responsible party (RP, a person who is accountable for making decisions on behalf of the resident) with access to an advocate who could inform them of their rights and from being inappropriately transferred. Findings: During a review of Residents 11 and 58's electronic health records regarding their transfers to an acute care hospital, on several occasions, a transfer notification form, that is to be sent to the Ombudsman, was not located. During an interview with the social services director (SSD), on 1/31/25 at 10:22 a.m., the SSD stated the facility do not have any notification forms to the Ombudsman for Residents 11 or 58. The SSD stated the facility did not have an Ombudsman since May of 2024 and did not notify the Ombudsman office of any transfers/discharges, since May of 2024. During a review of a list of residents who were transferred/discharged from May 2024 through January 2025, the list indicated 98 discharge/transfers since May 2024, with only seven notifications to the Ombudsman in January 2025. During an interview with the SSD on 1/31/25 at 12:40 p.m., the SSD stated each resident who was transferred or discharged , from May 2024 through January 2025, was listed; if they went out more than once they were listed each time. Neither the Ombudsman nor the resident or their representative received a notice of transfer/discharge, except the ones in January of this year. During a review of the facility's policy, titled Transfer and Discharge (including AMA), revised 12/19/2022, indicated .4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand.7. The facility will maintain evidence that the notice was sent to the Ombudsman.12. Emergency Transfer/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 5 of 20 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 01/31/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview, and record review, the facility failed to implement and develop a comprehensive care plan for one of 18 residents (Resident 67), when Resident 67's dementia (a general term for a group of brain disorders that cause a decline in cognitive abilities, such as memory, thinking, reasoning, and problem-solving) diagnosis was not addressed. This failure had the potential to result in the inability to identify the residents' individualized care issues and implement person-centered care. Findings: During a review of Resident 67's care plans, in his electronic health record, a care plan regarding his dementia was not found. During an interview with the facility's nurse consultant (NC) on 1/29/25 at 8:43 a.m., the NC stated Resident 67 should have a specific cognitive care plan. The NC acknowledged Resident 67 did not have a dementia care plan. During a review of the facility's policy, titled Dementia Care, revised 12/19/2022, the policy indicated .3. The care plan interventions will be related to each resident's individual symptomology and rate of dementia (or related disease) progression with the end result being noted improvement or maintained of ;the expected stable rate of decline associated with dementia and dementia-like illnesses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 6 of 20 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 01/31/2025 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 ensure needed care and services were provided in accordance with the resident's goals for care for one resident (Resident 38) out of six sampled residents, when Resident 38's physician's order for interaction was not followed. Residents Affected - Few This failure had the potential to put Resident 38 at risk for decline in physical, mental and psychosocial well-being. Findings: During a concurrent observation and interview on 1/27/25 at 8:55 a.m. with Resident 38, Resident 38 was lying in bed, awake, alert and oriented. Resident 38 stated I'm trying to get counseling for emotional situation. I get very irritable at people and I scream. During a concurrent observation and interview on 1/30/25 at 10:55 a.m. with Licensed Vocational Nurse (LVN) A, Resident 38 was lying in his bed. LVN A stated that Resident 38 was not in a wheelchair this morning. LVN A also stated that she never saw Resident 38 in a wheelchair even when Resident 38 was in a different station. During a concurrent observation and interview on 1/31/25 at 9:23 a.m. with Resident 38, Resident 38 was lying in his bed. Resident 38 stated he was not put in a wheelchair this morning. A review of Resident 38's medical records indicated diagnoses of but are not limited to, major depressive disorder (a mental condition that causes a persistent low mood, loss of interest and hopelessness), mood disorder (a mental health condition that causes extreme emotional states, such as depression and mania), and muscle weakness. A review of Resident 38's Physician's Orders indicated, Resident needs to be up in a wheelchair in the morning; one time a day every Mon [Monday], Wed [Wednesday], Fri [Friday] for interaction. A review of facility's policy and procedure (P&P) titled, Provision of Physician Ordered Services revised 5/15/23, the P&P indicated, .4. Activity restrictions: Nursing and support staff will ensure compliance with activity restrictions prescribed by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 7 of 20 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 01/31/2025 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 ensure a resident receiving dialysis (removal of waste and excess fluid from the body) treatment received consistent care with professional standards for one out of two sampled residents (Resident 32) when their dialysis communication sheets (DCS) were missing for several treatment days. This failure had the potential for Resident 32's dialysis care not being properly communicated and putting Resident 32 at risk for complications. Residents Affected - Few Findings: Review of Resident 32's clinical record indicated she was admitted on [DATE] with a diagnosis of cerebrovascular accident (CVA, also known as stroke, a brain disorder caused by lack of blood flow to the brain), and end-stage renal disease (when the kidneys no longer function to remove waste from the blood). Review of Resident 32's clinical record further indicated Resident 32 received dialysis on Tuesday, Thursday and Saturday. Review of Resident 32's dialysis record indicated there were missing DCS forms from 1/16/25-1/28/25. During a concurrent interview and record review with the Interim Director of Nursing (IDON) on 1/30/25 at 2:56 p.m., the IDON stated the DCS forms should be kept in the resident's chart or in white binder that goes with the resident from the facility to the dialysis center, and then back to the facility. The IDON confirmed there was no DCS forms from 1/16/25-1/28/25 for Resident 32. Review of the facility's policy titled Hemodialysis, last revised 6/5/23, indicated .The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to .Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility .Physician/treatment orders, laboratory values, and vital signs .Dialysis treatment provided .Dialysis adverse reactions/complications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 8 of 20 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 01/31/2025 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 appropriate pharmaceutical services when: Residents Affected - Some 1. Two medications, glipizide and duloxetine, were not available for two out of seven residents (Residents 224 and 55) 2. There were discrepancies between the controlled drug (those with high potential for abuse and addiction record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for four out of four residents (Residents 224, 32, 1 and 2) These failures had the potential to affect the health of residents and resulted in the facility not having accurate accountability of controlled medications which had the potential for misuse or diversion. Findings: 1. During a medication pass observation on 1/28/25 at 4:41 p.m., LVN F stated she did not have glipizide (medication that lowers blood sugar) 5 milligram (mg, unit of measurement) in the medication cart for Resident 224, and that she would have to call the pharmacy to get it stocked. A review of Resident 224's physician orders, dated 10/29/24, indicated Resident 224 was to receive glipizide 5 mg tablet two times a day for hyperglycemia [high blood sugar] related to TYPE 2 DIABETES MELLITUS [chronic condition when the body could not produce insulin that could lead to high blood sugar levels]. During a follow up interview with LVN F on 1/28/25 at 4:45 p.m., LVN F stated she would call to get an order for a one-time dose of glipizide at 8 p.m., that day to make up for the dose missed. During a medication pass observation on 1/29/25 at 8:53 a.m., LVN F stated she did not have duloxetine (a medication used to treat depression [feeling of sadness]) 30 mg in the medication cart for Resident 55, and that she would have to call the pharmacy to get it stocked. A review of Resident 55's physician orders, dated 6/18/24, indicated Resident 55 was to receive duloxetine 30 mg Give 3 capsule by mouth one time a day for m/b [manifested by] feelings of sadness related to SCHIZOAFFECTIVE DISORDER [a mental health condition], UNSPECIFIED. Review of the facility's policy titled Organizational Aspects-IA1: Provider Pharmacy Requirements, effective date April 2008, indicated The provider pharmacy agrees to perform the following pharmaceutical services .Providing routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hours per day, seven days per week .Medications which should be promptly available such as anti-infectives, as well as drugs used to treat problems .All other new medication orders are received and available for administration on the day they are ordered . 2. During the survey, four random CDRs for four residents (Residents 224, 32, 1 and 2) were requested for review. On 1/30/25 at 11 a.m., a review of the residents' physician orders, the CDRs and MARs indicated the following: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 9 of 20 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 01/31/2025 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 Residents Affected - Some a. Resident 224 had a physician order, dated 10/14/24 for oxycodone (a medication that can treat moderate to severe pain) 5 mg 1 tablet by mouth every 4 hours as needed for moderate to severe pain (7-10). Resident 224 had two instances which were recorded in the CDR but not documented as given in the MAR: on 1/10/25 at 6 p.m. and 1/28/25 at 7:15 p.m. b. Resident 32 had a physician order, dated 10/5/24 for oxycodone 5 mg 1 tablet via G-tube [a thin, flexible tube inserted surgically through the stomach that can be used for delivering nutrition, and medications when a person is unable to eat or drink orally] every 4 hours as needed for pain scale of 7-10 [severe pain]. Resident 32 had seven instances which were recorded in the CDR but not documented as given in the MAR: 1/7/25 at 5 a.m., 1/12/25 at 5 a.m., 1/15/25 at 4 a.m., 1/20/25 at 11:30 a.m., 1/22/25 at 4 a.m., 1/25/25 at 6:06 a.m., 1/26/25 at 11:30 p.m., and 1/27/25 at 10:48 p.m. c. Resident 1 had a physician order, dated 12/31/24, for Roxicodone (Oxycodone HCl) oral tablet 5 mg Give 3 tablet by mouth every 6 hours as needed for Sever pain scale 7-10. Resident 1 had three instances which were recorded in the CDR but not in the MAR: on/1/12/25 at 12:30 p.m., on 1/16/25 at 9 a.m., and on 1/18/25 at 5:02 p.m. d. Resident 2 had a physician order, dated 11/5/23, for oxycodone 5 mg Give 2 tablet by mouth every 4 hours as needed for Pain Management for severe pain 7-10. Resident 2 had six instances which were recorded in the CDR but not documented as given in the MAR: on 1/14/25 at 10:35 p.m., 1/17/25 at 7 a.m., 1/18/25 at 7 a.m., 1/23/25 at 2 p.m., 1/25/25 at 10 p.m., and 1/26/25 at 7 a.m. During a concurrent interview and record review with the interim Director of Nursing (IDON) on 1/30/25 at 2:56 p.m., the IDON reviewed the residents' respective CDRs and MARs: a. For Resident 224, the IDON verified the recorded dates in the CDR and the MAR and confirmed the findings above. b. For Resident 32, the IDON verified the recorded dates in the CDR and the MAR and confirmed all findings except 1/7/25, which she was able to verify as recorded in the MAR and 1/22/25, which was recorded in the CDR as given at 0400, but in the MAR it was recorded as given at 6:28 a.m. The IDON stated that whatever time the medication was taken out and recorded in the CDR should be the time in the MAR as well. c. For Resident 1, the IDON verified the recorded dates in the CDR and the MAR and confirmed all findings except 1/16/25, which was recorded in the CDR at 9 a.m. but recorded in the MAR at 10:42. The IDON stated that this was not okay, that the times should match between the CDR and the MAR. d. For Resident 2, the IDON verified the recorded dates in the CDR and MAR and confirmed the above findings. The IDON further stated that all controlled medications should be recorded in the MAR and the CDR when they were given. Review of the facility's policy titled Controlled Substance Administration & Accountability, last revised 6/5/23, indicated .In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 10 of 20 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 01/31/2025 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. Based on interview and record review, the consultant pharmacist (CP) failed to identify and report irregularities during the medication regimen review (MRR) for two (Resident 25 and Resident 174) out of 23 sampled residents when: 1. Abnormal Involuntary Movement Scale (AIMS, a rating scale that measures the severity of abnormal movements) was not done for Resident 25; and 2. AIMS was not done for Resident 174. 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: 1. A review of Resident 25's medical record indicated a diagnosis of but is not limited to Schizoaffective Disorder (chronic mental health condition in which people experience mood disorder, symptoms include hallucinations and/or delusions; feelings of intense sadness). A review of Resident 25's Physician Order dated 7/4/24 indicated, Seroquel Oral Tablet [antipsychotic medication] 300 mg [milligram, a unit of measurement]; give one tablet by mouth in the morning for m/b [manifested by] visual hallucination related to schizoaffective disorder. A review of Resident 25's Physician Order dated 7/16/23 indicated, Monitor for side effects to use of psychotropic medications. During a concurrent interview and record review of Resident 25's medical records with the CP on 1/31/25 at 9:52 a.m., the CP verified Resident 25 was on antipsychotic medication, Quetiapine (Seroquel). The CP also verified AIMS was not done for Resident 25. The CP stated, the facility should have done it initially and every six months. The CP also stated, since 2022, according to the facility, they do not use AIMS and we did not recommend AIMS since then. The CP also stated, I don't know what they do in replacement of AIMS. A review of the facility's policy and procedure (P&P) titled, Use of Psychotropic Medication revised 12/19/22, the P&P indicated, .11. The effects of the psychotropic medications on a resident' physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to: .b.During the pharmacist's monthly medication regimen review. A review of facility's policy and procedure (P&P) titled, Consultant Pharmacist Services Provider Requirements dated October 2017, the P&P indicated, .E. Activities that the consultant pharmacist or off-site pharmacist performs includes, but is not limited to: 1 a A residents's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in: iii. Without adequate monitoring 2. A review of Resident 174's medical records indicated diagnosis of but is not limited to paranoid schizophrenia (a condition typically affects your thinking abilities, memories, and senses). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 11 of 20 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 01/31/2025 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 A review of Resident 174's Physician Orders indicated, Risperidone Oral Tablet Disintegrating 1 mg; give 0.5 tablet by mouth two times a day for paranoia related to paranoid schizophrenia. During a concurrent interview and record review of Resident 174's medical records with the CP on 1/31/25 at 9:59 a.m., the CP verified Resident 174 was on antipsychotic medication, Risperidone. The CP verified that the AIMS was last done on 9/24/21 for Resident 174. The CP stated AIMS was last recommended to the facility in December 2022 and the facility said they use a different system. The CP also stated, I don't know what they do in replacement of AIMS. A review of facility's policy and procedure (P&P) titled, Use of Psychotropic Medication revised 12/19/22, the P&P indicated, .11. The effects of the psychotropic medications on a resident' physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to: .b. During the pharmacist's monthly medication regimen review . A review of facility's policy and procedure (P&P) titled, Consultant Pharmacist Services Provider Requirements dated October 2017, the P&P indicated, .E. Activities that the consultant pharmacist or off-site pharmacist performs includes, but is not limited to: 1 a A residents's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in: iii. Without adequate monitoring FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 12 of 20 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 01/31/2025 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** 1c. Review of Resident 23's clinical record indicated Resident 23 was admitted on [DATE] with diagnoses of cerebral vascular accident (also known as stroke, a disorder of the brain caused by lack of blood flow), and schizoaffective disorder (a disorder of the brain that can cause people to see and hear things that are not real). Review of Resident 23's clinical record indicated Resident 23 had an order, dated 10/26/24, for Risperidone 0.25 milligram (mg, unit of measurement) Give 1 tablet by mouth two times a day for m/b auditory hallucinations related to Schizoaffective disorder. Review of Resident 23's medical record indicated there was no AIMS assessment documented anywhere in the electronic chart. During an interview with the Pharmacy Consultant (PC) on 1/31/25 at 10:05 AM, the PC said an AIMS assessment should have been done for Resident 23. 1d. Review of Resident 70's clinical record indicated Resident 70 was admitted on [DATE] with diagnoses of deconditioning and schizoaffective disorder (a disorder of the brain that can cause people to see and hear things that are not real). Review of Resident 70's clinical record indicated Resident 70 had an order for Olazapine 2.5 mg by mouth daily for schizoaffective disorder. Review of Resident 70's medical record indicated there was no AIMS assessment documented anywhere in the electronic chart. During an interview with the Pharmacy Consultant (PC) on 1/31/25 at 10:05 AM, the PC said an AIMS assessment should have been done for Resident 70. Based on observation, interview, and record review, the facility failed to ensure four of 18 sampled residents (Residents 23, 25, 70 and 174) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications when Abnormal Involuntary Movement Scale (AIMS, a rating scale designed to measure involuntary movements known as tardive dyskinesia [TD], a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications) assessment was not done. The failure resulted in lack of adequate monitoring and unnecessary medications for the residents, which had the potential for increased risks associated with the use of psychotropic medications. Findings: 1a. A review of Resident 25's medical record indicated a diagnosis of but is not limited to Schizoaffective Disorder (chronic mental health condition in which people experience mood disorder, symptoms include hallucinations and/or delusions; feelings of intense sadness) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 13 of 20 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 01/31/2025 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 A review of Resident 25's Physician Order dated 7/4/24 indicated, Seroquel Oral Tablet [antipsychotic medication] 300 mg [milligram, a unit of measurement]; give one tablet by mouth in the morning for m/b [manifested by] visual hallucination related to schizoaffective disorder A review of Resident 25's Physician Order dated 7/16/23 indicated, Monitor for side effects to use of psychotropic medications. A review Lexicomp indicated, Quetiapine [Seroquel] may cause extrapyramidal symptoms (EPS), also known as drug-induced movement disorders. The EPS include tardive dyskinesia (TD, an involuntary movement disorder that causes a range of repetitive muscle movements in the face, neck, arms and legs). During a concurrent interview and record review of Resident 25's medical records with the Consultant Pharmacist (CP) on 1/31/25 at 9:52 a.m., the CP verified Resident 25 was on antipsychotic medication, Quetiapine (Seroquel). The CP also verified Abnormal Involuntary Movement Scale (AIMS) was not done for Resident 25. The CP stated, the facility should have done it initially and every six months. The CP also stated, since 2022, according to the facility, they do not use AIMS and we did not recommend AIMS since then. The CP also stated, I don't know what they do in replacement of AIMS. 1b. A review of Resident 174's medical records indicated diagnosis of but is not limited to paranoid schizophrenia (a condition typically affects your thinking abilities, memories, and senses). A review of Resident 174's Physician Orders indicated, Risperidone Oral Tablet Disintegrating 1 mg [milligram, unit of measurement]; give 0.5 tablet by mouth two times a day for paranoia related to paranoid schizophrenia During a concurrent interview and record review of Resident 174's medical records with the Consultant Pharmacist (CP) on 1/31/25 at 9:59 a.m., the CP verified Resident 174 was on antipsychotic medication, Risperidone. The CP verified that Abnormal Involuntary Movement Scale (AIMS) was last done on 9/24/21 for Resident 174. The CP stated AIMS was last recommended to the facility in December 2022 and the facility said they use a different system. The CP also stated, I don't know what they do in replacement of AIMS. During a concurrent interview and record review with the Interim Director of Nursing (IDON) on 1/31/25 at 11:07 a.m., the IDON stated the facility does not have a specific form to monitor abnormal involuntary movements for residents on psychotropic medications. The IDON also stated, she does not remember the frequency of AIMS. The IDON also verified the facility had no specific form/assessment in replacement of AIMS. A review of facility's policy and procedure (P&P) titled, Use of Psychotropic Medication revised 12/19/22, the P&P indicated, .11. The effects of the psychotropic medications on a resident' physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as but not limited to: .b.During the pharmacist's monthly medication regimen review . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 14 of 20 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 01/31/2025 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 facility medication error rate of 7.7% when four errors out of 52 opportunities during the medication administration for four out of six residents (Residents 12, 224, 55 and 2). This failure resulted in medication not given in accordance with the prescriber's orders which had the potential for residents not receiving the full therapeutic effects of the medications. Residents Affected - Some Findings: 1. During a concurrent medication pass observation and interview on 1/27/25 at 12:31 p.m., with LVN E, LVN E administered three units (standard measurement) of insulin aspart (a type of insulin injection to lower blood sugar level) to Resident 12 with a pen injector (an injector that uses a dial to administer the correct medication dosage). Prior to administering the 3 units, LVN E did not prime (process of filling the tubing) the pen injector needle with two units. LVN E stated I would usually prime the needle with 2 units. Review of UpToDate: Lexidrug (a drug reference for healthcare professionals) indicated for insulin aspart administration .For prefilled pen injectors, prime the needle before each injection with 2 units . 2. During a concurrent medication pass observation and interview on 1/28/25 at 4:41 p.m., with LVN F, LVN F stated she did not have glipizide (medication used to lower blood sugar level) 5 milligram (mg, unit of measurement) on hand to give to Resident 224 along with her other medications at the time. LVN F stated she would need to call the physician to get an order to give the medication at a later time and to call the pharmacy to refill the medication. Review of Resident 224's physician orders, dated 10/29/24, indicated Glipizide Oral Tablet 5 mg Give 1 tablet by mouth two times a day for hyperglycemia related to TYPE 2 DIABETES MELLITUS [high blood sugar level] WITH UNSPECIFIED COMPLICATIONS. Review of the facility's policy titled Provision of Physician Ordered Services, last revised 5/15/23, indicated .Medication administration and therapeutic treatments; Qualified nursing personnel will administer medications as ordered by the physician .Medications will be administered following facility protocols, dosage guidelines, and documentation procedures. 3. During a concurrent medication pass observation and interview on 1/29/25 at 8:53 a.m., with LVN F, LVN F stated she did not have duloxetine (medication used to treat depression [feelings of sadness] and anxiety [feelings of excessive worry and fear]) 30 mg on hand to give to Resident 55 along with his other medications at the time. During a follow up interview on 1/29/25 at 9 a.m.,, LVN F stated she would have to contact the pharmacy to restock the duloxetine, and that It's important to keep the medication cart stocked with their medications. Review of Resident 55's physician orders, dated 6/18/24, indicated Duloxetine HCL Oral Capsule Give 3 capsules by mouth one times a day for m/b feelings of sadness related to SCHIZOAFFECTIVE DISORDER [mental disorder], UNSPECIFIED. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 15 of 20 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 01/31/2025 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's policy titled Medication Administration, dated 12/19/22, indicated Keep medication cart clean, organized, and stocked with adequate supplies. 4. During a concurrent medication pass observation and interview on 1/29/25 at 8:53 a.m., with LVN F, LVN F administered Ketotifen eye drops (a medication that treats dryness in the eyes) in both the right and left eye, for Resident 55. The label on the box the eye drops indicated Instill 1 drop in right eye two times a day for dry eyes. LVN F confirmed what was on the label, and stated It's supposed to be both eyes I think .oh, it's just the right eye. Review of Resident 55's physician order's, dated 101/4/24, indicated Ketotifen Fumarate Opthalmic Solution 0.035% Instill 1 drop in right eye two times a day for dry eyes. Review of the facility's policy titled Administration of Eye Drops or Ointments, dated 12/19/22, indicated .Verify orders and labeling prior to administration .Compare the label with the order to verify correct medication, dose, route and time of administration .Confirm which eye requires treatment . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 16 of 20 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 01/31/2025 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 safe and sanitary conditions were maintained for food storage according to standards of practice and facility policy when: Residents Affected - Some 1. There were expired food items; 2. Cookware was not properly dried; 3. The temperature log book for the refrigerator used to store food for residents was incomplete. These deficient practices potentially exposed 65 residents, who received food from the kitchen to food-borne illnesses. Findings: 1. During the initial tour of the facility's kitchen on 1/27/25 at 8:32 a.m., with the dietary aide, (DA), the following were observed: a. Gelatin in refrigerator R3 which had an expiration date of 1/26/25. b. Refrigerator R2 had Ground beef which had an expiration date of 1/26/25. c. Freezer F1 had a bag of 4 buns with a date of 12/16/24. d. One pie crust had dates of 12/16/24 and use by 1/16/24. 2. During an observation and subsequent interview, with the dietary manager (DM), on 1/29/25 at 10:51 a.m., there were seven large metal sheet pans which were stacked wet on storage rack. During a subsequent interview with the DM, she stated the trays should not be wet. 3. During a record review and subsequent interview, with the director of staff development (DSD), on 1/30/25 at 3:08 p.m., the refrigerator in the medication room, at station one/two, used for food brought in by visitors, had a temperature log for January 2025 which missing temperatures for 1/28/25, for a.m. and p.m., on 1/29/25, for a.m., and p.m., and on 1/30/25 for a.m. The DSD acknowledged that the temperatures were missing, and should have been there. During a review of the facility's procedure, titled Dish and Utensil Procedure, with an unreadable revision date, indicated .6. Dishes, trays, and utensils shall be air dried before storage. Do not towel dry. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 17 of 20 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 01/31/2025 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 Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when: Residents Affected - Some 1. Staff did not label resident wash basins kept in shared bathrooms with the residents' identifiers; 2. Staff did not wear the proper personal protective equipment (PPE) when entering a room under enhanced droplet precautions; 3. Staff did not label oxygen tubing for one resident (Resident 21); 4. Staff did not ensure the dressing around a gastrostomy tube (GT, a thin, flexible tube inserted through the stomach to deliver nutrients or medications) was intact and correct infection precaution was followed for one resident (Resident 7); and 5. A urinary catheter (a device that drains urine) bag was found touching the floor, for one resident (Resident 38). These failures had the potential to compromise resident's health and safety, and potentially lead to the spread of communicable illnesses. Findings: 1. During an observation on 1/27/25 at 8:52 a.m., two unlabeled wash basins were seen in the shared bathroom of resident room AA. During an observation on 1/27/25 at 9:44 a.m., one unlabeled wash basin was seen on top of the paper towel dispenser in the shared bathroom of resident room BB. During an interview with Certified Nursing Assistant G on 1/29/25 at 11:06 a.m., CNA G stated wash basins should be labeled with the resident's name and room number. During an interview with the Interim Director of Nursing (IDON), the IDON stated resident items such as urinals should be labeled with the resident's name and room number. 2. During an observation on 1/29/25 at 8:58 a.m., the IDON and Licensed Vocational Nurse F (LVN F) went into resident room CC wearing a gown, gloves and N-95 mask (a specialized type of face mask that offers more protection than a regular face mask). A sign on the door for resident room CC indicated Enhanced Droplet Precautions, to include a gown, gloves, a N-95 mask and a faceshield. The IDON and LVN F did not don (wear) a faceshield before they entered resident room CC. During an observation on 1/29/25 at 9:45 a.m., the Maintenance Supervisor (MS) went into resident room CC wearing a gown, gloves, and a regular face mask. The MS also did not don a faceshield before entering resident room CC. During an interview with the IDON on 1/29/25 at 9 a.m., the IDON stated enhanced droplet precautions should be gown, gloves and N-95 mask. The IDON stated she did not know about the use of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 18 of 20 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 01/31/2025 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 faceshields with enhanced droplet precautions. Level of Harm - Minimal harm or potential for actual harm During an interview with the MS on 1/31/25 at 10:31 a.m., the MS stated that he looks at the sign that was posted on the door to know what PPE to wear in a room. Residents Affected - Some During an interview with the infection preventionist (IP), the IP stated Enhanced Droplet Precautions are all PPE, including gown, gloves, face shield and N-95 mask. The IP also stated that all staff have been given a recent in-service on the correct use of PPE. Review of the facility's policy titled Personal Protective Equipment, dated 12/19/22, indicated All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. 3. During an observation on 1/28/25 at 9:06 a.m., Resident 21 was seen lying in bed, wearing a nasal cannula device (a device that goes in the nostrils to deliver oxygen). The tubing did not have a label with a date or initials. During an interview with LVN I on 1/31/25 at 10:39 a.m., LVN I stated oxygen tubing should be labeled with the date when the oxygen tubing was changed. Review of the facility's policy titled Oxygen Administration, last revised 5/20/24, indicated .Change oxygen tubing and mask/cannula weekly and as needed . 4. During an observation on 1/27/25 at 9:08 a.m. with CNA C in Resident 7's bedside, an Enhanced Barrier Protection sign was visible on Resident 7's wall on top of the bed. CNA C was wearing gloves but was not wearing a gown while changing Resident 7's under pad and briefs. Resident 7 had a GT covered in gauze and tape dated 1/25. The GT dressing was loose and tape on the edges were not adhering on the skin. During an interview on 1/27/25 at 9:20 a.m. with CNA C, CNA C stated he did not know if he should wear a gown while doing close contact care for Resident 7. During a concurrent observation and interview on 1/27/25 at 1:19 p.m. with LVN H, LVN H stated, Resident 7's GT dressing was changed every day shift. LVN H verified the date on Resident 7's GT dressing was 1/25. LVN H also stated, CNAs must wear gown when changing Resident 7's briefs. During an interview on 1/30/25 at 1:32 p.m. with the IP, the IP stated that residents who have GT are on Enhanced Barrier Precaution and staff must wear face mask, gown and gloves when doing high-contact procedures or anything procedures that involve touching the resident. The IP also stated that Resident 7's GT dressing must be changed every night shift and as needed. A review of Resident 7's medical records indicated a diagnosis of but is not limited to Dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or throat) and Gastrostomy Status (a surgical procedure used to insert a tube through the abdomen and into the stomach). A review of resident 7's active physician orders indicated, Enhance Barrier Precaution every shift for Enteral feeding [GT feeding] requirement. PPE [personal protective equipment] : Clean hands before and after leaving room, gown and gloves. It also indicated, GT site: Cleanse with NS [normal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 19 of 20 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 01/31/2025 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 saline, sterile solution of water and salt], pat dry, apply dressing every day shift. Level of Harm - Minimal harm or potential for actual harm A review of facility's policy and procedures (P&P) titled, Enhanced Barrier Precautions revised 6/17/2024, the P&P indicated, .3. Implementation of Enhance Barrier Precautions: b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .4. High-contact resident care activities include: d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting . Residents Affected - Some A review of facility's policy and procedure (P&P) titled, Personal Protective Equipment revised 12/19/22, the P&P indicated, .1. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. 5. During an observation on 1/30/25 at 10:39 a.m. with CNA B in Resident 38's bedside, CNA B verified that Resident 38's urine bag was touching the floor. During an interview on 1/30/25 at 1:32 p.m. with the IP, the IP stated that urine bags must not touch the floor. A review of Resident 38's medical records indicated a diagnosis of but is not limited to obstructive and reflux uropathy (a condition in which the flow of urine is blocked). A review of facility's policy and procedure (P&P) titled Appropriate Use of Indwelling Catheters revised 12/19/22, the P&P indicated, .9. Indwelling urinary catheters .will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible. Possible complications include, but are not limited to: urinary tract infection, blockage of the catheter, expulsion of the catheter, pain, discomfort, and bleeding . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555635 If continuation sheet Page 20 of 20