Deficiencies (last 4 years)
Deficiencies (over 4 years)
11.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
188% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
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 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 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 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, 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: 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
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
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
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. |
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