Inspection·July 28, 2023

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some She stated AD walked out of the job on 4/15/2023 since then there was no AD. She also stated AA was not trained to assist residents to organize RCM. She further stated last RCM was in October last year. During a concurrent review and interview with administrator (ADMN) on 6/13/2023 at 3:35 p.m., ADMN confirmed last RCM was on 10/20/2022. He stated activity staff should have followed facility's policy to assist, organize, and participate in RCM every month. Review of facility's policy and procedure (P&P) titled, Resident Council, undated, the P&P indicated, The facility's policy was to implement a resident council meeting that will convene for a minimum for one hour on a monthly basis. organize, schedule, and assist each council meeting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 2 of 8 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0679 Provide activities to meet all resident's needs. 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 to follow their policy and procedure for activities when: Residents Affected - Some 1. There were no scheduled adequate ongoing sensory stimulation activities provided to residents; 2. There were no one to one room visits provided to meet resident's centered activities for Resident 1,2,3, and 4; 3. Incomplete comprehensive activity assessment for Resident 4; 4. There was no person-centered care plan for activities for Resident 4. This failure had the potential to prevent 39 residents (currently residing in facility) from receiving meaningful activities to enhance their physical, cognitive, and emotional health, assessment for activities and person-centered care plan to meet Resident's individual needs for activities. Findings: 1.Review of facility's monthly calendar for activities for May/2023 indicated, scheduled group activities on 5/18/2023 including flag arts at 2:30 p.m., card games at 3:30 p.m., and Elvis [NAME] songs at 4:30 p.m. During multiple observations on 5/18/2023 at 2:30 p.m., 2:45 p.m., 3:30 p.m., and 3:40 p.m., group activities not provided to residents as scheduled at 2:30 p.m., and 3:30 p.m., in activity room. Review of Resident 2's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 2 admitted to facility on 9/12/2017 with diagnoses including cerebral infraction (a medical condition where the blood circulation in the brain suddenly disrupted), hypertension (blood pressure that is higher than normal), and psoriasis (a skin disease that causes a rash with itchy, and scaly patches). Resident 2 was her own responsible for decision making. Review of her MDS assessment dated [DATE] indicated BIMS score of 15/15, intact cognition. During an interview with Resident 2 on 5/18/2023 at 1:00 pm., Resident 2 stated activities in dining room were not provided as scheduled on daily basis. Review of Resident 5's (resident council president) face sheet indicated Resident 5 admitted to facility on 2/12/2021 with diagnoses including diabetes type 2 (a chronic condition that affects the way the body processes blood sugar), cerebral infarction (occurs as a result of disrupted blood flow to the brain), and epilepsy (chronic neurological disorder by repeated sudden uncontrolled burst of electrical activity in the brain). Resident 5's minimum date set (MDS-clinical and functional assessment tool) dated 7/2/2023 indicated her brief interview for mental status (BIMS) score of 15 of 15 (13-15: intact cognition). During an interview with Resident 5 on 6/13/2023 at 1:15 p.m., Resident 5 stated scheduled group activities were not providing to residents routinely. Resident 5 also stated staff were providing activities in the facility on hit and miss basis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 3 of 8 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with certified nursing assistant A (CNA A) on 5/18/2023 at 12:30 p.m., she confirmed scheduled activities were not providing to residents on a regular basis. She stated currently there was no activity director and activity assistant working 5 days a week. She also stated residents were watching TV in their rooms or in the activity room most of the time. During an interview with licensed vocational nurse B (LVN B) on 5/18/2023 at 3:10 p.m., LVN B confirmed there was no flag arts activity provided to resident today at 2:30 p.m., as scheduled. During an interview with director of staff development/minimum date set coordinator (DSD/MDSC) on 5/18/2023 at 3:45 p.m., DSD/MDSC confirmed scheduled group activities for 5/18/2023 at 2:30 p.m., and 3:30 p.m., were not provided to residents. She also stated activity director walked out from job on 4/14/2023, and activity assistant (AA) not working today to provide these activities to residents. She further stated activity staff should have provided group activities to residents as scheduled. During an interview with AA on 6/13/2023 at 12:30 p.m., AA confirmed stated group activities were not provided to residents as scheduled on routine basis. He also stated when he was off for two days a week, there was no activity staff in facility to do activities for residents. He further stated should be provided activities to residents 7 days a week as scheduled. 2.Review of Resident 1's face sheet indicated Resident 1 admitted to facility on 5/27/2017 with diagnoses including diabetes type 2 (a chronic condition that affects the way the body processes blood sugar), adult failure to thrive (a general state of decline), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Resident 1 was her own responsible for decision making. Review of her minimum date set (MDS-clinical assessment tool) assessment dated [DATE] indicated her brief interview for mental status (BIMS) score of 13/15 (13-15: intact cognition). Review of Resident 1's activity participation notes indicated there were two one to one visit notes for period of three-week period on 5/9/2023, and 5/13/2023. During an interview with Resident 1 on 5/18/2023 at 12:50 p.m., Resident 1 stated activity staff comes to her room to do one to one activity sometimes not on regular basis. She also stated not interested to go to activity room, she liked to stay in room. Review of Resident 2's activity notes indicated there was one note for one-to-one visit on 5/13/2023 for past three- weeks period. During an interview with Resident 2 on 5/18/2023 at 1:00 p.m., she stated activity person came to her room once to deliver flowers on Mother ' s Day. She also stated activity director (AD) used to come to her room to play bingo with her often in the past. Review of Resident 3's face sheet indicated Resident 3 admitted to facility on 5/10/2023 with diagnoses including left femur fracture (broken left thigh bone), right bimalleolar fracture (broken right ankle bones), osteoporosis (a condition in which bones becomes weak and brittle) and hypertension. Resident 3 had assigned resident representative (RP) for decision making. Her MDS assessment dated [DATE] indicated BIMS score of 13/15, intact cognition. Review of Resident 3's activity notes indicated there was one note for one-to-one visit on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 4 of 8 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0679 5/13/2023 for one week period. Level of Harm - Minimal harm or potential for actual harm During an interview with Resident 3 on 6/13/2023 at 12:58 p.m., she stated activity person came once to her room to deliver flowers to celebrate Mother's Day. She also stated currently she was focusing on getting better to go home, not bothered for activities. Residents Affected - Some Review of Resident 4's face sheet indicated Resident 4 admitted to facility on 5/2/2023 with diagnoses including hepatic failure (loss of liver function), diabetes type 2, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and adult failure to thrive. Resident 3 was her own decision maker. Her MDS assessment dated [DATE] indicated her BIMS score of 15/15, intact cognition. Resident was discharged home on 6/8/2023. Review of Resident 4's activity notes indicated there were three one-to-one visit notes on 5/13/2023, 5/16/2023, and 5/26/2023 for past six weeks period. During an interview with CNA A on 5/18/2023 at 12:30 p.m., CNA confirmed there were no one to one activity for residents as needed on routinely. CNA A stated AA working five days a week, he was by himself, trying his best to provide activities to residents when he was here. During in interview with AA on 6/13/2023 at 3:15 p.m., AA confirmed he did not provide one to one activity for Resident 1,2,3, and 4. AA stated he was providing few in room activities for residents in a week. AA also stated he should have offered one to one in room activity for these residents three times per week. During a concurrent review and interview with DSD/MDSC on 6/13/2023 at 3 3:25 p.m., DSD/MDSC confirmed one to one in room activity notes for Resident 1,2,3, and 4. DSD/MDSC stated activity staff should have provided one on one activity for these residents three times per week. 3.Review of Resident 4's activities - initial review assessment dated [DATE] indicated, incomplete assessment. During an interview with AA on 6/13/2023 at 3:15 p.m., AA confirmed initial activity assessment for Resident 4's was incomplete. AA stated he should have completed the initial assessment for Resident 4 upon her admission. During a concurrent review and interview with DSD/MDSC on 6/13/2023 at 3:25 p.m., DSD/MDSC confirmed Resident 4's initial activity assessment was incomplete. DSD/MDSC stated activity staff should have completed initial activity assessment for Resident 4. 4.Review of Resident 4's care plans indicated there was no comprehensive care plan for activities. During an interview with AA on 6/13/2023 at 3:15 p.m., AA confirmed there was no care plan for activities for Resident 4. He stated he should have completed care plan for Resident 4. During a concurrent review and interview with DSD/MDSC on 6/13/2023 at 3 3:25 p.m., DSD/MDSC confirmed there was no care plan for activities for Resident 4. She stated activity staff should have completed care plan for activities for Resident 4. Review of facility's policy and procedure (P&P) titled, Group Activity Planning, undated, the P&P (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 5 of 8 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated, Activity programs will provide opportunities for each resident to meet their social, physical, cognitive, and emotional needs/interest through a variety of group, individual or independent participation. Activity programs will be provided seven days a week. Review of facility's P&P titled, One-on-one and /or in-room cart, undated, the P&P indicated, A resident who can not come to the activity room to join the group or preferred to stay inside the room should be provided activities at least 2X-3X a week. Review of facility's P&P titled, Documentation, Activities, revised January 2020, the P&P indicated, The following records, at a minimum, are maintained by activity department personnel: a. Activities evaluation e. Individualized activities care plan or activities portion of the comprehensive care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 6 of 8 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the activity program directed by a qualified therapeutic recreation specialist. This failure had resulted in all thirty residents not received meaningful activity to enhance their physical, cognitive, and emotional well-being. Residents Affected - Some Findings: During facility visit on 5/18/2023 from 11:34 a.m., to 4:40 p.m., there were no activity director (AD), or activity assistant (AA) working in facility. During facility visit on 6/13/2023 from 10:15 a.m., to 3:47 p.m., there was no AD working in facility. Review of Resident 5's undated face sheet, indicated Resident 5 admitted to facility on 2/12/2021 with diagnoses including diabetes type 2 (a chronic condition that affects the way the body processes blood sugar), cerebral infarction (occurs as a result of disrupted blood flow to the brain), and epilepsy (chronic neurological disorder by repeated sudden uncontrolled burst of electrical activity in the brain). Resident 5's minimum date set (MDS-clinical and functional assessment tool) dated 7/2/2023 indicated her brief interview for mental status (BIMS) score of 15 of 15 (13-15: intact cognition). During an interview with Resident 5 on 6/3/2023 at 3:05 p.m., Resident 5 stated she was the resident council president and she stated there was no activity director. She also stated CNA staff and AA were providing activities in the facility on a hit and miss basis. During an interview with certified nursing assistant A (CNA A) on 5/18/2023 at 12:30 p.m., CNA A confirmed currently there was no AD working in facility. CNA A stated there was no AD since April/2023 and AA comes to work five days a week. CNA A also stated scheduled group and one to one room visit activities for residents were not offered when AA was off. During an interview with licensed vocational nurse B (LVN B) on 5/18/2023 at 3:10 p.m., LVN B stated currently there was no AD working in facility. LVN B stated no scheduled activities were providing to residents since AD left the job. During an interview with AA on 6/13/2023 at 12:30 p.m., AA confirmed there was no AD. He stated he was not a certified activity professional. He also stated currently he was enrolled in certification course. During an interview with director of staff development/minimum data set coordinator (DSD/MDSC) on 6/13/2023 at 1:12 p.m., DSD/MDSC confirmed currently there was no AD working in the facility. She also stated AA was not a certified activity staff and he was currently attending activity certification course and working five days a week in the facility. During an interview with administrator (ADMN) on 6/13/2023 at 2:47 p.m., ADMN confirmed currently there was no AD working in the facility. He stated AA was not qualified and certified for a activity director position as required. The AA currently enrolled in activity certification program to become AD. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 7 of 8 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0680 Level of Harm - Minimal harm or potential for actual harm Review of facility's policy and procedure (P&P) titled, Activity Director, undated indicated, To ensure the coordination, development and implementation of activity services and programs using staff experience, family, and community resources. The Activity Director needs possess the educational and experience requirements. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 8 of 8