Health inspection·February 1, 2024

F 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. Based on observations, interviews, and facility document review, the facility failed to ensure residents' rooms accommodated no more than four residents when 1 (Ward 1) of 23 resident rooms was occupied by six residents, and 1 (Ward 2) of 23 resident rooms was occupied by four residents but had six beds available for use when at full occupancy. Findings included: Review of the facility's Resident Matrix, printed 01/29/2024, revealed six residents occupied room ward 1. During observations on 01/31/2024 beginning at 1:35 PM, six residents were observed to occupy [NAME] 1. [NAME] 2 was occupied by four residents but had six beds available for use when at full occupancy. During an interview on 02/01/2024 at 9:40 AM, Licensed Vocational Nurse #1 stated he had never had an issue with providing care to the residents. During an interview on 02/01/2024 at 9:45 AM, Certified Nursing Assistant #2 stated he had no issues providing proper care to the residents. During an interview on 02/01/2024 at 10:34 AM, the Director of Nursing (DON) stated he expected residents' rooms to be large enough to be safe for the residents who resided in them, for the staff to provide care for the residents, and spacious to accommodate the residents' personal belongings. During an interview on 02/01/2024 at 10:40 AM, the Administrator stated he believed there could be no more than four residents in a room. The Administrator stated he expected that residents' rooms would still have adequate space for their personal use and belongings, as well as space to provide adequate care. 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 4 Event ID: 555838 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 555838 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Camden Postacute Care, Inc 1331 Camden Avenue Campbell, CA 95008 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)