Inspection·January 9, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to follow it's Policy and Procedure titled Isolation-Initiating Transmission- Based Precautions, when the facility failed to implement the transmission-based precautions for isolation precaution (process of creating barriers between people and germs to help prevent the spread of infectious microbes) when residents develop signs and symptoms of productive cough and suspected of respiratory illness during the outbreak for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5). This failure had the potential to spread infectious disease to other residents and staff at the facility. Residents Affected - Some Findings: During an interview on 12/10/24 at 10:08 a.m., with the Infection Prevention Nurse (IP), the IP stated in March 2024 about eight to nine residents with symptoms of runny nose and cough were reported. The IP stated they notified the doctor to get an order for cough and an order for isolation precaution related to respiratory illness outbreak then placed residents on isolation. During a review of the Long-Term Care Respiratory line list (an excel spreadsheet of all persons involved in the outbreak) the spreadsheet indicated, nine (9) residents had respiratory symptoms (runny nose and cough) from 3/5/24 to 3/7/24 during the respiratory illness outbreak. The spreadsheet indicated 1 staff member had respiratory related symptoms on 2/24/24. 1. During a review of Resident 1's SBAR communication (a structured communication tool that stands for Situation, Background, Assessment, and Recommendation.) dated 3/04/24, the SBAR indicated, Resident was noted to have a persistent cough, non-productive. During a review of Resident 1's physician's order dated 3/11/24, physician's order indicated, guaifenesin (used to relieve chest congestion) oral liquid 100 milligram (mg, unit of measure)/5 milliliter (ml) give 10 ml by mouth every 4 hours as needed for cough/congestion for 14 days. There was no documented evidence for Resident 1 was on isolation precautions during respiratory illness outbreak. During a review of Resident 1's Care plan dated 3/05/24, Care plan indicated, Resident has persistent non-productive cough. During a concurrent interview and record review on 12/10/24 at 11:20 a.m., with the IP, she stated there was no physician order of isolation precaution related to respiratory illness outbreak for Resident 1. IP stated there should have a physician order for isolation precaution. The IP stated, there was no evidence documenting Resident 1 was placed on isolation during the respiratory illness outbreak. (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 3 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 01/09/2025 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)