Inspection·December 5, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review the facility failed to exercise the resident's right as a resident of the facility for one out of three resident (Resident 1) when Resident 1 was not allowed to leave out on pass to get her Covid-19 (Covid-19: a sickness caused by virus called severe acute respiratory syndrome coronavirus 2) booster vaccine (lessens the severity of Covid-19 by teaching the person's immune system to recognize and fight the virus that causes the disease) outside the facility. This failure had the potential to effect on health and well-being to Resident 1 Findings: During record review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated, Resident 1 admitted to facility on 11/8/2021 and discharged home on 1/3/2022. Resident 1's admission diagnoses including compression fracture of T11-T12 vertebra (broken bones of the spine[Spine: column of bones running from head down to the lower back]), osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when quality or structure of bone changes), and bronchiectasis (a condition in which the lungs' airways become damaged, making it hard to clear mucus). Review of Resident's minimum data set (MDS: clinical and functional assessment tool) dated 11/4/2021 indicated, Resident 1's brief interview for mental status (BIMS) indicated Resident 1 had short-term (forgetting information to which the subject has been recently exposed) and long- term (trouble recalling the information previously learned) memory problem. Review of Resident1's immunization record from acute hospital (a level of healthcare wherein a resident receives immediate yet brief treatment) dated 11/4/2021 indicated, Resident 1 received Covid-19 vaccine o 1/28/2021 and 3/11/2021. Review of Resident 1's electronic medical record (digital version of resident's health record) for psychological note dated 12/22/2021 indicated, Resident 1's family member requested for resident to be taken out of the facility to get Covid-19 booster vaccine at healthcare clinic in local community. This note further indicated facility staff explained to family member that Resident 1 was on Medicare (the federal health insurance program covers in-patient care in skilled nursing facilities [SNF: an in-patient rehabilitation and medical treatment center staffed with trained medical professionals), and family were not supposed to go on leave of absence unless it was an emergency, and Resident 1 was not able to receive her Covid-19 booster vaccine during her stay in facility. During an interview with facility's infection preventionist (IP) on 12/1/2023 at 2:08 p.m., IP (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555757 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 12/05/2023 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)