Inspection·June 21, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide supervision to prevent one of two residents (Resident 1) who were at risk for elopement from leaving the facility without staffs' knowledge and permission when Resident 1's wander guard (device used to keep track of residents), was not checked for functionality and staff did not provide Resident 1 with supervision or assistance. These failures compromised Resident 1's safety, as she was found outside of the facility. Findings: Review of Resident 1's admission record indicated, Resident 1 was readmitted to the facility on [DATE] with diagnoses including unspecified dementia (loss of memory), unspecified severity, with other behavioral disturbance, essential primary hypertension (occurs when the abnormally high blood pressure was not a result of a medical condition), mixed hyperlipidemia (high levels of fat particles in the blood), and history of falling. Review of Resident 1's interdisciplinary team (IDT, brings together knowledge from different health care disciplines to help residents with their needs) note dated 4/5/24, indicated, Resident 1 had episode of elopement on 3/31/24. Review of Resident 1's IDT note dated 4/10/24, Resident 1 had episode of elopement on 4/7/24 and was found in the street outside of the facility. Review of Resident 1's minimum data set (MDS, a standardized assessment tool that measures health status in nursing home residents), dated 1/26/24, indicated, Resident 1 needed supervision or assistance with walking and her activities of daily living (ADL, activities related to personal care). Review of Resident 1's post elopement care plan interventions, initiated on 4/1/24, indicated, to monitor wander guard placement every shift to left wrist and to monitor Resident 1's whereabouts frequently. During an interview with licensed vocational nurse A (LVN A) on 5/1/24 at 7:46 a.m., LVN A verified that the wander guard bracelet of Resident 1 was not checked that was the reason the staff did not notice Resident 1 went out of the facility. LVN A further verified that the whereabouts of Resident 1 was not regularly checked. During an interview with the certified nursing assistant B (CNA B) on 6/20/24 at 2:51 p.m., CNA B (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 06/21/2024 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)