Health inspection·July 24, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to follow it's Policy & Procedure (P&P) titled, Abuse Reporting and Investigation for three of four sampled residents (Resident 1, Resident 2, and Resident 3) when: Residents Affected - Some 1. The facility failed to complete a 5-day investigative report for Resident 1's abuse allegation and send the report to the California Department of Public Health (CDPH). 2. The facility failed to complete a 5-day investigative report for Resident 2's abuse allegation and send the report to the CDPH. 3. The facility failed to complete a 5-day investigative report for Resident 3's abuse allegation and send the report to the CDPH. These failures had the potential for Resident 1, 2, and 3's abuse allegations to not be investigated thoroughly and resulted in CDPH being unaware of the outcome of each investigation by the facility. Findings: 1. During a review of Residents 1's SOC 341 (Report of Suspected Dependent Adult/Elder abuse) dated 12/18/23 indicated, an allegation of abuse was reported to CDPH. Report indicated, Resident 1 reported a physical abuse allegation to staff, involving Resident 4. During an interview on 7/23/24, at 10 a.m., with Director of Nursing (DON), DON stated, she could not find a 5-day report for Resident 1's abuse allegation. DON stated, the Administrator was the abuse coordinator for the facility. During an interview on 7/23/24, at 2:12 p.m., with Administrator (ADM), ADM stated he was unable to provide a 5-day report for Resident 1's abuse allegation. Administrator stated, there should have been one for each abuse allegation. 2. During a review of Residents 2's SOC 341 dated 12/13/23 report indicated, an allegation of abuse was reported to CDPH. Report indicated, Resident 2 reported a physical abuse allegation to staff, involving Resident 4. During an interview on 7/23/24, at 10 a.m., with Director of Nursing (DON), DON stated, she could not find a 5-day report for Resident 2's abuse allegation. (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: 555831 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 555831 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Herman Health Care Center 2295 Plummer Avenue San Jose, CA 95125 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)