Deficiencies (last 4 years)
Deficiencies (over 4 years)
23 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
475% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 19, 2025
Visit Reason
The inspection was conducted due to a complaint regarding failure to establish and communicate which licensed nurse was responsible for providing care to a resident, resulting in delayed medication administration.
Complaint Details
The complaint was substantiated. The investigation confirmed confusion about nurse assignments on the evening shift, leading to delayed medication administration for Resident 1.
Findings
The facility failed to ensure clear communication of nurse assignments for Resident 1 on the evening shift of 4/9/25, causing delayed administration of scheduled medications. Licensed vocational nurse A administered medications nearly two hours late due to confusion about nurse responsibility.
Deficiencies (1)
F 0684: The facility failed to establish and communicate which licensed nurse was responsible for providing care to Resident 1 on the evening shift of 4/9/25, resulting in delayed medication administration and potential unmet care needs.
Report Facts
Medication administration delay: 2
Medication scheduled times: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse A | Nurse Supervisor | Administered Resident 1's medications late on 4/9/25 and provided interview details about nurse assignment confusion |
| Licensed Vocational Nurse B | Scheduled nurse for Resident 1's area on 4/9/25 but was requested not to provide care | |
| Licensed Vocational Nurse C | Supposed to take over care for Resident 1 on 4/9/25 but was not informed |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 19, 2025
Visit Reason
The inspection was conducted due to a complaint regarding failure to establish and communicate which licensed nurse was responsible for providing care to Resident 1 on the evening shift of 4/9/25, resulting in delayed medication administration.
Complaint Details
The complaint investigation found that the failure to communicate nurse assignments was substantiated, resulting in delayed medication administration to Resident 1 on 4/9/25.
Findings
The facility failed to ensure clear communication of nurse assignments on the evening shift of 4/9/25, causing Resident 1 to receive scheduled medications late, specifically insulin lispro administered nearly two hours after the scheduled time. Licensed Vocational Nurse A administered the medications late due to confusion about nurse assignments, and Licensed Vocational Nurse C was not informed she was to provide care to Resident 1.
Deficiencies (1)
Failure to establish and communicate which licensed nurse was responsible for providing care to Resident 1 on the evening shift, resulting in delayed medication administration.
Report Facts
Medication administration delay: 2
Scheduled medications: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse A | Nurse Supervisor | Administered Resident 1's medications late on 4/9/25 and explained nurse assignment confusion |
| Licensed Vocational Nurse B | Scheduled to provide care to Resident 1 on 4/9/25 but was requested not to | |
| Licensed Vocational Nurse C | Supposed to provide care to Resident 1 on 4/9/25 but was not informed |
Inspection Report
Annual Inspection
Capacity: 75
Deficiencies: 12
Date: Mar 7, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and ensure resident care and safety at San Jose Healthcare & Wellness Center.
Findings
The facility was found deficient in multiple areas including resident dignity, informed consent for psychotropic medications, medication administration, care plan adherence, medication storage, dietary sanitation, arbitration agreement explanation, infection control practices, and room size compliance. Deficiencies were generally of minimal harm but had potential risks to residents.
Deficiencies (12)
Failure to treat residents with dignity when a nurse opened a resident's door without covering her while exposed.
Failure to properly obtain informed consent for psychotropic medications for three residents.
Medications left unattended at bedside for a resident not approved for self-administration.
Failure to provide ordered dietary items and apply prescribed medical devices for residents.
Failure to ensure proper use of bed rails including lack of care plans, physician orders, and consents.
Failure to fully administer medications via gastrostomy tube due to residue remaining in medication cups.
Failure to store and label medications and biologicals according to manufacturer instructions and facility policy.
Failure to ensure kitchen staff competently carried out food and nutrition service functions, including improper dish machine sanitizer testing.
Failure to maintain safe and sanitary conditions in the kitchen including unlabeled/past use-by date foods and dirty sink drainage pipe.
Failure to explain arbitration agreement to residents resulting in signing without full understanding.
Failure to follow proper infection control procedures including hand hygiene before vital signs, feeding, meal checks, and wound care.
Failure to ensure bedrooms met minimum square footage requirements per resident.
Report Facts
Residents affected: 14
Residents affected: 6
Medications: 12
Medications with residue: 6
Residents affected: 51
Rooms: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse A | LVN | Named in dignity violation and infection control deficiencies |
| Certified Nursing Assistant C | CNA | Named in dialysis care, feeding, and infection control deficiencies |
| Registered Nurse E | RN | Named in medication storage and medication administration deficiencies |
| Licensed Vocational Nurse D | LVN | Named in medication administration and infection control deficiencies |
| Licensed Vocational Nurse B | LVN | Named in care plan adherence deficiency |
| Registered Nurse F | RN | Named in infection control deficiencies |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including informed consent and medication administration |
| Admission Director | AD | Interviewed regarding arbitration agreement explanation |
| Dietary Manager | DM | Interviewed regarding kitchen sanitation and dish machine sanitizer testing |
| Registered Dietician | RD | Interviewed regarding dietary deficiencies and kitchen sanitation |
| Dish Machine Vendor Technician Specialist | TS | Interviewed regarding proper dish machine sanitizer testing |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 7, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging that a staff member shouted at a resident who expressed hunger and failed to acknowledge the resident's statement.
Complaint Details
The complaint was substantiated. The investigation found that staff shouted at Resident 14 when she expressed hunger and failed to respond respectfully. Multiple interviews with staff including the Dietary Manager, Registered Dietician, and Director of Nursing confirmed inappropriate staff behavior and lack of proper response to resident needs.
Findings
The facility failed to ensure one resident was free from abuse when staff shouted at the resident and did not acknowledge her hunger statement. Observations, interviews, and record reviews confirmed the incident and identified policy violations regarding resident rights and staff conduct.
Deficiencies (1)
F 0600: The facility failed to protect a resident from verbal abuse when staff shouted at Resident 14 who expressed hunger and did not respond appropriately. This failure had the potential to impact the resident's physical and mental well-being.
Report Facts
Residents sampled: 14
Weight loss percentage: 11.3
Brief Interview for Mental Status (BIMS) score: 12
Date of admission: Jun 8, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) G | Interviewed regarding Resident 14's eating independence | |
| Dietary Manager (DM) | Observed shouting at Resident 14 and not wearing hair covering in kitchen | |
| Regional Registered Dietician (RRD) | Interviewed about appropriate response to resident hunger | |
| Dietary [NAME] (DC) | Interviewed about staff conduct toward residents | |
| Director of Nursing (DON) | Interviewed about kitchen staff conduct and resident rights |
Inspection Report
Routine
Deficiencies: 12
Date: Mar 7, 2025
Visit Reason
Routine inspection of San Jose Healthcare & Wellness Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to treat residents with dignity, improper informed consent for psychotropic medications, medication administration errors, improper use of bed rails, inadequate medication storage, food safety issues, failure to explain arbitration agreements, lapses in infection control, and insufficient resident room space.
Deficiencies (12)
F 0550: The facility failed to treat Resident 31 with dignity when a nurse opened the room door without covering the resident's exposed back and buttocks.
F 0552: The facility failed to obtain proper informed consent for psychotropic medications for Residents 20, 4, and 28, compromising residents' rights to be fully informed.
F 0554: The facility failed to prevent medications from being left unattended at Resident 4's bedside, who was not approved for self-administration.
F 0684: The facility failed to provide ordered treatments for Residents 3 and 21 and failed to ensure CNA knowledge of Resident 23's care needs.
F 0700: The facility failed to ensure proper documentation and consent for bed rail use for six residents, risking entrapment and injury.
F 0755: The facility failed to ensure Resident 21 received full prescribed medication doses via gastrostomy tube due to residue remaining in medication cups.
F 0761: The facility failed to store and label medications properly, including refrigeration requirements and open dates, risking incorrect or unsafe medication administration.
F 0802: The facility failed to ensure kitchen staff correctly tested the dish machine sanitizer, risking foodborne illness for 51 residents.
F 0812: The facility failed to maintain safe and sanitary food storage and preparation conditions, including unlabeled or expired foods and dirty sink drainage pipe.
F 0847: The facility failed to explain the arbitration agreement to Residents 23 and 31 before obtaining their signatures, resulting in lack of informed consent.
F 0880: The facility failed to ensure proper infection control practices, including hand hygiene before feeding and meal handling, and cleaning of equipment used in wound care.
F 0912: The facility failed to ensure 10 bedrooms met the minimum required 80 square feet per resident, potentially compromising care and services.
Report Facts
Residents affected: 14
Residents affected: 6
Residents affected: 51
Number of medications: 12
Room measurements: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse A | LVN | Named in dignity and infection control findings |
| Director of Nursing | DON | Interviewed regarding informed consent and medication administration deficiencies |
| Registered Nurse E | RN | Named in medication storage and administration findings |
| Certified Nursing Assistant C | CNA | Named in infection control and resident care knowledge findings |
| Licensed Vocational Nurse D | LVN | Named in infection control and medication administration findings |
| Director of Nursing | DON | Confirmed bed rail and medication administration deficiencies |
| Admission Director | AD | Interviewed regarding arbitration agreement explanation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding potential abuse of Resident 14 by staff who shouted at the resident and did not acknowledge her statement of hunger.
Complaint Details
The complaint was substantiated based on observations, interviews, and record reviews showing staff verbal abuse towards Resident 14, including shouting and dismissive behavior when Resident 14 expressed hunger.
Findings
The facility failed to ensure Resident 14 was free from abuse when staff shouted at her and ignored her hunger statement. Observations and interviews confirmed the Dietary Manager shouted 'Go to your room!' at Resident 14, which was inappropriate and against facility policies promoting respectful treatment of residents.
Deficiencies (1)
Failure to protect Resident 14 from verbal abuse by staff shouting and ignoring her hunger statement.
Report Facts
Residents sampled: 14
Weight loss percentage: 11.3
Brief Interview for Mental Status (BIMS) score: 12
Date of admission: Jun 8, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Observed shouting at Resident 14 and holding kitchen door |
| Licensed Vocational Nurse G | Licensed Vocational Nurse | Interviewed regarding Resident 14's eating independence |
| Regional Registered Dietician | Regional Registered Dietician | Interviewed about appropriate response to resident hunger |
| Director of Nursing | Director of Nursing | Interviewed about kitchen staff conduct and resident respect |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 13, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure that medications were administered as ordered to a resident and to verify the completeness and accuracy of the resident's medical record documentation.
Complaint Details
The investigation was complaint-driven, focusing on medication administration failures and medical record documentation issues for Resident 1. The complaint was substantiated with findings of missed medication administration and lack of physician notification documentation.
Findings
The facility failed to administer prescribed medications to one resident despite receiving them from the pharmacy. Additionally, the facility failed to document notification to the resident's physician about the missed medications, compromising communication and care tracking.
Deficiencies (2)
F 0755: The facility failed to ensure one resident received medications as ordered by the physician. Medications delivered on 8/3/24 were not administered on 8/3 and 8/4/24 because staff could not locate them.
F 0842: The facility failed to maintain complete and accurate medical records for one resident by not documenting notification to the physician about multiple medications that were not administered.
Report Facts
Medications ordered: 4
Dates medications not administered: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Acknowledged medications were on order but not administered due to pharmacy delay. |
| Licensed Nurse B | Licensed Nurse | Confirmed medications were not administered because they could not be found and admitted failure to document physician notification. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to ensure a resident received medications as ordered and failure to maintain complete and accurate medical records related to medication administration.
Complaint Details
The complaint investigation found substantiated failures related to medication administration and medical record documentation for Resident 1, including failure to administer medications despite pharmacy delivery and failure to document physician notification of missed medications.
Findings
The facility failed to ensure one resident received prescribed medications as ordered, despite the medications being delivered to the facility. Nurses documented medications as 'on order' but did not administer them due to inability to locate the medications. Additionally, the facility failed to document notification to the resident's physician about the missed medications, compromising communication and care tracking.
Deficiencies (2)
Failure to ensure one resident received medications as ordered by the physician.
Failure to maintain complete and accurate medical records, including lack of documentation that the physician was notified of missed medications.
Report Facts
Medication delivery time: 2.31
Number of residents sampled: 3
Dates of medication non-administration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse A | Licensed Nurse | Acknowledged medications were 'on order' and not administered due to lack of medication availability. |
| Licensed Nurse B | Licensed Nurse | Confirmed medications were not administered due to inability to locate them and admitted failure to document physician notification. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 29, 2024
Visit Reason
The inspection was conducted following a complaint regarding an altercation between two residents involving physical contact and potential neglect in care and monitoring.
Complaint Details
The complaint involved an incident on 1/11/24 where Resident 2 threw cold coffee on Resident 1. The facility failed to properly document and communicate the incident and follow up care. The deficiencies were substantiated based on interviews and record reviews.
Findings
The facility failed to complete required communication and documentation after an altercation between two residents, including failure to complete an SBAR, notify physicians and responsible parties, perform a skin assessment, conduct alert charting, and follow up after a room change. These failures posed potential risks to the residents' health and safety.
Deficiencies (4)
F 0684: The facility failed to complete an SBAR and notify the physician and responsible party after an altercation between two residents occurred on 1/11/24.
F 0684: Licensed nurses did not perform a skin assessment on Resident 1 after Resident 2 threw coffee on her on 1/11/24.
F 0684: Licensed nurses did not document alert charting for 72 hours following the altercation between Resident 1 and Resident 2.
F 0684: Staff did not follow up or document Resident 2's adjustment after a room change on 1/11/24.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse A | Licensed Vocational Nurse | Interviewed regarding failure to perform skin assessment and documentation after the altercation. |
| Director of Nursing | Director of Nursing | Interviewed and confirmed failures in documentation, notification, and follow-up related to the incident. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 29, 2024
Visit Reason
The inspection was conducted following a complaint regarding an altercation between two residents, Resident 1 and Resident 2, involving physical aggression and inadequate follow-up care.
Complaint Details
The complaint involved an incident on 1/11/24 where Resident 2 threw cold coffee on Resident 1. The facility failed to complete required assessments, notifications, and documentation following the incident. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to provide care according to professional standards by not completing required communication (SBAR), not notifying physicians and responsible parties, not performing a skin assessment after the incident, not documenting alert charting for 72 hours, and not following up after a room change. These failures posed potential risks to residents' health and safety.
Deficiencies (4)
Staff did not complete an SBAR and did not notify the physician and responsible party after an altercation between residents.
Licensed nurse did not perform a skin assessment for Resident 1 after coffee was thrown on her.
Licensed nurses did not put Resident 1 and Resident 2 on alert charting for 72 hours following the altercation.
Staff did not follow up with Resident 2 after a room change.
Report Facts
Residents sampled: 3
Residents affected: 2
Alert charting duration: 72
Date of incident: Jan 11, 2024
Date of room change: Jan 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed and confirmed failures in documentation and notification |
| Licensed Vocational Nurse A | Licensed Vocational Nurse | Interviewed and confirmed lack of skin assessment documentation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 11, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to notify the Ombudsman of resident transfers and discharges, and to assess compliance with oxygen therapy policies.
Complaint Details
The complaint investigation found that the Ombudsman office had not received notifications of transfers and discharges from the facility since July 2023. The facility confirmed no documentation existed for notifying the Ombudsman about the discharges or transfers of Residents 1, 2, and 3.
Findings
The facility failed to notify the Ombudsman of discharges or transfers for three residents, violating notification requirements. Additionally, the facility did not follow its Oxygen Therapy policy for two residents by using unlabeled nasal cannulas and failing to post No Smoking signs in oxygen use areas.
Deficiencies (2)
F 0623: The facility failed to provide timely notification to the Ombudsman of resident discharges and transfers for three residents, risking lack of advocacy for their rights.
F 0695: The facility failed to follow its Oxygen Therapy policy for two residents by using an unlabeled nasal cannula and not posting No Smoking signs in the resident's room.
Report Facts
Residents affected: 3
Physician's order date: Feb 6, 2024
Physician's order date: Nov 10, 2023
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 11, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to notify the Ombudsman of resident discharges and transfers, and to assess compliance with oxygen therapy policies.
Complaint Details
The complaint investigation confirmed that the Ombudsman office had not received notifications of transfers and discharges from the facility since July 2023. The facility lacked documentation of notifying the Ombudsman for three residents' discharges or transfers.
Findings
The facility failed to notify the Ombudsman of discharges or transfers for three residents, violating notification requirements. Additionally, the facility did not follow its Oxygen Therapy policy for two residents by having unlabeled nasal cannulas and missing No Smoking signs in oxygen use areas.
Deficiencies (3)
Failure to ensure timely notification to the Ombudsman of resident discharges and transfers for three residents.
Failure to label Resident 4's nasal cannula with a date as required by policy.
Failure to post No Smoking sign in Resident 5's room where oxygen was administered.
Report Facts
Residents affected: 3
Physician's order date: Feb 6, 2024
Physician's order date: Nov 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding notification procedures and documentation of Ombudsman notifications. |
| Licensed Nurse A | Licensed Nurse | Confirmed unlabeled nasal cannula and absence of No Smoking sign in Resident 5's room. |
| Ombudsman office representative B | Ombudsman Office Representative | Confirmed no receipt of notification of resident discharges and transfers since July 2023. |
| Administrator | Administrator | Presented fax cover sheet documentation related to Ombudsman notifications. |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication administration, restorative nursing services, staff performance evaluations, pharmaceutical services, food safety, and room size requirements at San Jose Healthcare & Wellness Center.
Findings
The facility was found deficient in multiple areas including failure to replace missing hearing aids for a resident, improper medication administration, inadequate restorative nursing services, incomplete performance reviews for nursing assistants, discrepancies in controlled medication records, improper food storage, and insufficient bedroom space for residents.
Deficiencies (7)
Failed to ensure replacement of missing hearing aids for Resident 34, resulting in over nine months without hearing aids.
Failed to follow physician's orders when a licensed vocational nurse did not administer medication as prescribed to Resident 152.
Failed to provide Restorative Nursing Assistance services as ordered for Resident 16, resulting in missed therapy sessions.
Failed to complete annual performance review for CNA E, resulting in lack of evaluation and feedback.
Failed to ensure complete records for controlled medications; discrepancies found between narcotic count sheets and Medication Administration Records for Residents 13, 43, and 153.
Failed to ensure food was stored according to professional food safety standards; outdated graham cracker crumbs found and ice chest stored on the floor.
Failed to ensure 10 bedrooms met minimum space requirements of at least 80 square feet per resident.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Ice chest volume: 85
Room measurements: 10
Room sizes: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse F | Licensed Vocational Nurse | Named in medication administration deficiency for Resident 152 |
| Certified Nursing Assistant E | Certified Nursing Assistant | Named in failure to complete annual performance review |
| Social Services Director | Social Services Director | Interviewed regarding missing hearing aids for Resident 34 |
| Director of Nursing | Director of Nursing | Interviewed regarding medication record discrepancies and restorative nursing services |
| Restorative Nursing Aide A | Restorative Nursing Aide | Interviewed regarding missed restorative nursing services for Resident 16 |
| Certified Nursing Aide B | Certified Nursing Aide | Interviewed regarding missing hearing aids for Resident 34 |
| Licensed Vocational Nurse C | Licensed Vocational Nurse | Interviewed regarding missing hearing aids for Resident 34 |
| Director of Staff Development | Director of Staff Development | Interviewed regarding CNA E performance review |
| Dietary Director | Dietary Director | Interviewed regarding food storage deficiencies |
| Registered Dietician Nutritionist | Registered Dietician Nutritionist | Interviewed regarding food storage deficiencies |
Inspection Report
Routine
Deficiencies: 8
Date: Oct 20, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory standards in various areas including resident care, medication administration, restorative nursing services, staff performance evaluations, pharmaceutical services, food safety, and room size requirements.
Findings
The facility was found deficient in multiple areas including failure to provide assistive hearing devices, medication administration errors, inadequate restorative nursing services, incomplete staff performance reviews, discrepancies in controlled medication records, improper food storage, and insufficient bedroom space per resident.
Deficiencies (8)
F 0557: The facility failed to ensure Resident 34 received replacement hearing aids missing since December 2022, resulting in the resident being without hearing aids for over nine months.
F 0658: The facility failed to follow physician's orders when a licensed vocational nurse did not administer medication to Resident 152 as prescribed, resulting in the resident not receiving the ordered medication.
F 0685: The facility failed to ensure Resident 34 received assistive hearing devices when her bilateral hearing aids were missing since December 2022, leaving her without hearing aids for over nine months.
F 0688: The facility failed to provide Restorative Nursing Assistance as ordered for Resident 16, resulting in missed therapy sessions and potential decreases in mobility.
F 0730: The facility failed to complete a performance review for CNA E at least once every 12 months, resulting in lack of evaluation and feedback for the employee.
F 0755: The facility failed to ensure complete records for controlled medications for Residents 13, 43, and 153, with medications signed out but not documented on the Medication Administration Record.
F 0812: The facility failed to ensure food was stored according to professional food safety standards, including outdated graham cracker crumbs in dry storage and an ice chest stored on the floor.
F 0912: The facility failed to ensure 10 bedrooms measured at least 80 square feet per resident, potentially compromising care and services.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Room measurements: 10
Room square feet per resident: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse F | Licensed Vocational Nurse | Named in medication administration error for Resident 152 |
| Certified Nursing Assistant E | Certified Nursing Assistant | Named in failure to complete annual performance review |
| Director of Nursing | Director of Nursing | Interviewed regarding medication discrepancies and restorative nursing staffing |
| Social Services Director | Social Services Director | Interviewed regarding missing hearing aids for Resident 34 |
| Dietary Director | Dietary Director | Interviewed regarding food storage violations |
| Registered Dietician Nutritionist | Registered Dietician Nutritionist | Interviewed regarding ice chest storage violation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 11, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to transfer a deceased resident's body to the mortuary within four hours after death.
Complaint Details
The complaint investigation found that the facility delayed releasing Resident 1's body to the mortuary beyond the required four hours, causing emotional distress to Residents 2, 3, and 4, who reported sadness, worry, loss of appetite, and disturbance from the odor.
Findings
The facility failed to ensure timely transfer of Resident 1's body to the mortuary, resulting in the body being kept over 12 hours and causing significant emotional distress to three other residents due to odor and prolonged presence of the body.
Deficiencies (1)
F 0684: The facility failed to transfer Resident 1's body to the mortuary within four hours after death, causing emotional distress to other residents due to odor and prolonged presence of the body.
Report Facts
Time body kept after death: 12
Time of death: 18.34
Time body released: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Released Resident 1's body to mortuary on 8/9/2023. |
| Certified Nursing Assistant B | CNA | Observed odor and fluid from Resident 1's body and reported residents' emotional distress. |
| Director of Nursing | DON | Interviewed regarding the delay and acknowledged staff should have released the body within four hours. |
| LVN C | Licensed Vocational Nurse | Attempted to find mortuary to release Resident 1's body and reported impact on work and resident distress. |
| Facility Administrator | Administrator | Confirmed delay due to miscommunication between nursing staff and previous DON. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 11, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to transfer a deceased resident's body to the mortuary within four hours after death, causing emotional distress to other residents.
Complaint Details
The complaint investigation found that the facility kept Resident 1's body beyond the four-hour limit, causing a strong odor and significant emotional distress to Residents 2, 3, and 4. The delay was due to miscommunication and difficulty in arranging mortuary pickup. Residents reported sadness, loss of appetite, and sleep disturbances related to the incident.
Findings
The facility failed to ensure timely transfer of Resident 1's body to the mortuary within four hours after death, resulting in a strong odor and emotional distress among three other residents. Interviews with staff and residents confirmed the delay and its negative impact, and the facility acknowledged miscommunication and procedural lapses.
Deficiencies (1)
Failure to transfer Resident 1's body to the mortuary within four hours after death.
Report Facts
Time body kept after death: 16.5
BIMS scores: 13
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Released Resident 1's body to mortuary and confirmed timing of release. |
| Certified Nursing Assistant B | CNA | Observed odor and fluid from Resident 1's body and reported residents' emotional distress. |
| Director of Nursing | DON | Acknowledged staff should have released body within four hours and confirmed emotional distress caused by delay. |
| LVN C | Licensed Vocational Nurse | Attempted to arrange mortuary pickup and reported impact on work and residents. |
| Facility Administrator | Administrator | Confirmed miscommunication caused delay in body release. |
Inspection Report
Routine
Deficiencies: 1
Date: Aug 2, 2023
Visit Reason
The inspection was conducted to assess compliance with pneumococcal vaccination policies and procedures at the nursing home.
Findings
The facility failed to follow its policy and CDC recommendations for pneumococcal vaccination for one sampled resident, who did not receive the recommended PPSV 23 vaccine 8 weeks after PCV 13. The infection preventionist was unaware of the CDC recommendation but planned to address the issue with the resident's physician and responsible party.
Deficiencies (1)
F 0883: The facility failed to offer and administer pneumococcal polysaccharide vaccine 23 (PPSV 23) to Resident 1 at least 8 weeks after receiving pneumococcal conjugate vaccine 13 (PCV 13) as recommended by CDC guidelines.
Report Facts
Residents affected: 1
Date survey completed: Aug 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist | Interviewed regarding pneumococcal vaccination policy and Resident 1's vaccination status |
Inspection Report
Deficiencies: 1
Date: Aug 2, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with pneumococcal vaccination policies and procedures, specifically regarding adherence to CDC recommendations for pneumococcal vaccines in residents.
Findings
The facility failed to follow its policy and procedure for pneumococcal vaccination for one of six sampled residents, who did not receive the recommended pneumococcal polysaccharide vaccine 23 (PPSV 23) eight weeks after receiving pneumococcal conjugate vaccine 13 (PCV 13), as recommended by CDC. The infection preventionist was unaware of the CDC recommendation and confirmed the resident was immunocompromised and living in the facility without receiving the PPSV 23 vaccine.
Deficiencies (1)
Failed to follow policy and procedure for pneumococcal vaccination for one resident by not administering PPSV 23 vaccine 8 weeks after PCV 13 vaccine as recommended by CDC.
Report Facts
Residents sampled: 6
Residents affected: 1
Date of resident admission: May 23, 2023
Date of survey completion: Aug 2, 2023
Date of infection preventionist interview: Aug 1, 2023
Date of facility policy revision: Feb 18, 2021
Inspection Report
Annual Inspection
Capacity: 75
Deficiencies: 1
Date: May 3, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of practice related to resident care, specifically focusing on fall prevention interventions for Resident 1.
Findings
The facility failed to implement fall care plan interventions for Resident 1, including keeping the bed in the lowest position and ensuring the call light was within reach, which posed a potential risk for further falls and injury.
Deficiencies (1)
Failure to ensure Resident 1's bed was in the lowest position and call light was within reach as per the fall care plan interventions.
Report Facts
Total licensed capacity: 75
Fall risk score: 18
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Acknowledged observations regarding Resident 1's bed position and call light placement |
| Director Of Nursing | Director Of Nursing | Stated staff should have followed fall care plan interventions for Resident 1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 3, 2023
Visit Reason
The inspection was conducted due to a complaint regarding failure to implement fall care plan interventions for Resident 1, specifically related to bed positioning and call light accessibility.
Complaint Details
The complaint was substantiated. Resident 1's fall care plan interventions were not followed, confirmed by observation and staff interviews. The Director of Nursing acknowledged the failure to follow the care plan.
Findings
The facility failed to ensure Resident 1's bed was kept in the lowest position and the call light was within reach as recommended by the interdisciplinary team. Observations and interviews confirmed these care plan interventions were not followed, posing potential risk for further falls and injury.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences. Resident 1's fall care plan interventions were not implemented as the bed was not in the lowest position and the call light was not within reach.
Report Facts
Fall risk score: 18
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse B (LVN B) | Acknowledged observations of bed not in lowest position and call light not within reach | |
| Director of Nursing (DON) | Acknowledged staff should have followed fall care plan interventions |
Inspection Report
Routine
Capacity: 75
Deficiencies: 13
Date: Dec 10, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, food service, and facility safety at San Jose Healthcare & Wellness Center.
Findings
The facility was found deficient in multiple areas including inaccurate PASRR screening documentation, incomplete implementation of care plans, medication administration errors, failure to complete physician laboratory orders, inconsistent drug reconciliation, improper medication storage, food safety violations, infection control lapses, and inadequate resident room space.
Deficiencies (13)
PASARR screening for Mental disorders or Intellectual Disabilities was inaccurately completed for two residents.
Failure to implement risk for fall care plan for one resident by not placing landing pad as ordered.
Failure to revise comprehensive care plan to include new interventions to prevent elopement for one resident.
Licensed nurses administered midodrine when systolic blood pressure was higher than ordered; laboratory orders for another resident were not completed.
Inconsistent signing of controlled drug count documents at change of shift for medication carts.
Consultant pharmacist recommendations for lab tests were not presented to the physician for one resident.
Medication error rate of 5.56% observed during medication passes for two residents.
Medications and biologicals were stored and labeled inappropriately, including undated glucose test strips and expired medication.
One kitchen staff lacked competency in final cooking temperatures and thermometer calibration.
Facility failed to follow planned menu portions for four residents on carbohydrate controlled diets.
Food safety violations including nursing refrigerators out of temperature range, lack of air gap in food prep sink, and wet food service equipment storage.
Multiple infection control failures including uncovered oxygen cannula, improper hand hygiene, failure to change syringe daily, lack of PPE use in yellow zone, improper cleaning of blood pressure cuffs and glucose meters.
Ten bedrooms measured less than 80 square feet per resident, below regulatory minimum.
Report Facts
Medication error rate: 5.56
Controlled drug count missing signatures: 13
Residents affected by room size deficiency: 10
Residents affected by infection control deficiencies: 12
Residents affected by medication errors: 2
Residents affected by PASRR screening deficiency: 2
Residents affected by care plan deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Confirmed Resident 3 left facility and care plan interventions for elopement were not revised. |
| RN B | Registered Nurse | Observed medication administration errors and failure to sanitize blood pressure cuff between residents. |
| LVN E | Licensed Vocational Nurse | Interviewed regarding controlled drug count and syringe use for Resident 43. |
| CNA J | Certified Nursing Assistant | Observed not sanitizing hands before feeding Resident 43. |
| CNA G | Certified Nursing Assistant | Observed entering yellow zone room without gown. |
| FSW A | Food Service Worker | Observed lacking knowledge of correct cooking temperatures and thermometer calibration. |
| DON | Director of Nursing | Confirmed multiple deficiencies including medication administration, lab orders, and infection control. |
| DSD | Director of Staff Development | Provided information on PPE requirements and infection control training. |
| RD | Registered Dietitian | Observed food service errors and confirmed lack of recent staff training on food safety. |
| HK H | Housekeeper | Observed not wearing appropriate PPE in yellow zone and improper gown removal. |
Inspection Report
Routine
Deficiencies: 13
Date: Dec 10, 2021
Visit Reason
Routine inspection of San Jose Healthcare & Wellness Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including inaccurate PASRR screening, incomplete care plans, medication administration errors, inconsistent drug reconciliation, improper medication storage, food safety violations, infection control lapses, and inadequate resident room sizes.
Deficiencies (13)
F0645 PASARR screening was inaccurately completed for two residents, failing to document diagnosed mental disorders.
F0656 The facility failed to implement the risk for fall care plan for one resident by not placing the landing pad as ordered.
F0657 The care plan was not revised to include new interventions to prevent recurrence of elopement for one resident.
F0684 Licensed nurses administered midodrine contrary to physician orders and laboratory tests were not completed for one resident.
F0755 The facility failed to maintain consistent drug reconciliation with missing signatures on controlled drug count documents.
F0756 Consultant pharmacist recommendations for lab tests were not presented to the physician for one resident.
F0759 The facility had a 5.56% medication error rate with two errors observed during medication passes.
F0761 Medications and biologicals were stored and labeled improperly, including undated glucose test strips and expired medication.
F0802 Kitchen staff lacked competency in final food temperature knowledge and thermometer calibration.
F0803 The facility failed to follow the planned menu for four residents on controlled carbohydrate diets.
F0812 Food safety violations included nursing refrigerators out of temperature range, lack of air gap in food prep sink, and wet food service equipment storage.
F0880 Infection control failures included uncovered oxygen cannula, improper hand hygiene, unclean equipment, and improper PPE use in isolation zones.
F0912 Ten bedrooms measured less than the required 80 square feet per resident, potentially compromising care.
Report Facts
Medication error rate: 5.56
Controlled drug count missing signatures: 13
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Rooms measured: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Confirmed no revised interventions to prevent recurrence of resident's elopement. |
| RN B | Registered Nurse | Observed medication administration errors and failure to sanitize BP cuff between residents. |
| LVN E | Licensed Vocational Nurse | Used syringe beyond recommended time and confirmed medication cart discrepancies. |
| CNA J | Certified Nursing Assistant | Did not sanitize hands after touching curtain before feeding resident. |
| FSW A | Food Service Worker | Lacked knowledge of correct final cooking temperatures and thermometer calibration. |
| HK H | Housekeeper | Did not wear appropriate PPE and improperly removed gown in yellow zone. |
| CNA G | Certified Nursing Assistant | Entered yellow zone room without gown and put gown on after entering. |
| DON | Director of Nursing | Confirmed multiple deficiencies including medication errors and infection control lapses. |
| DSD | Director of Staff Development | Confirmed PPE requirements and training deficiencies. |
| RD | Registered Dietitian | Confirmed food service and safety deficiencies. |
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