Milpitas Care Center

Inspectors wroteBased on interview, and record review, the facility failed to develop person -centered care plan that included target symptoms, measurable objectives, and interventions for five of five sampled residents (Resident 1, 2, 3, 4, and 5) when:1. No care plan for rehabilitation ((treatments and interventions aimed at improving functional abilities and quality of life) services/treatments for Resident 1, 2, 3, 4, and 5. Above failures had the potential to result in not meeting sampled residents' needs and plan of care.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) for progress notes, charting and documentation for therapy services (treatments and interventions aimed at improving functional abilities and quality of life) / treatments for five out of five sampled residents (Resident 1,2,3,4, and 5). This failure had potentially effect on plan of care, monitor functional progress, and communication for above sampled residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of 18 sampled residents (Resident 12) when Resident 12 experienced an unplanned insidious weight loss of 10 pounds, 6.8% in three months and 16 pounds 9.8% weight loss in six months. This had the potential to result in muscle wasting, loss of independence, decreased quality of life, and increased disease complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. While feeding the two residents (Residents 25 and 3) certified nursing assistant (CNA) E touched the resident cups without conducting hand hygiene between helping the residents; 2. While assisting a resident (Resident 25) with feeding, CNA E handled the drinking surface of resident's cup; 3. The dry food storage shelves were in poor condition; and 4. Certified Nursing Assistant H (CNA H) walked out of Resident 6's room, did not sanitize her hands, and shifted residents' lunch trays in the meal cart up and down. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 6 residents (5, 11, and 79) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 5 received Depakote (used to treat manic depressive illness) without monitoring for side effects and quarterly assessment; 2. Resident 11 received Depakote without quarterly assessment; and 3. Resident 79 received quetiapine (used to treat depressive and manic episodes), lorazepam (used to treat disorders that involve more than occasional worry or fear), haloperidol (used to treat nervous, emotional, and mental conditions), and bupropion (used to treat major depressive disorder) without monitoring for manifested behaviors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food that was regular and pureed potatoes were flavorful and served at a palatable temperature. These failures had the potential for residents who received potatoes to eat less and have a decreased amount of nutrient intake.

Inspectors wroteBased on interview and record review, the facility failed to inform and provide written information to one of 5 residents (5), regarding the rights to formulate an advance directive (a legal document that explains how a resident wants medical decisions about him/her to be made if he/she cannot make the decisions himself/herself. It is used to guide the health care team and loved ones when they need to make these decisions or to decide who will make decisions for the resident when he/she can't). This failure had the potential for the facility to provide treatment and services against the residents' wishes.

Inspectors wroteBased on interview and record review, the facility failed to provide that one of 3 residents (Resident 132) reviewed for the SNF Beneficiary Protection Notification Review received a written copy of the Notice of Medicare Non-Coverage (NOMNC) at least two calendar days before the end of Medicare Part A coverage. This failure denied Resident 132 the knowledge to appeal the discharge.

Inspectors wrote2. Review of Resident 10's admission Record indicated she was admitted to the facility on [DATE] with schizophrenia diagnosis. Review of Resident 10's PASARR Level I Screening, dated 11/22/22, indicated that Resident 10 did not have a serious diagnosed mental disorder such as schizophrenia. During an interview with registered nurse A (RN A) on 6/25/25, at 3:53 p.m., she reviewed Resident 10's 11/22/22 PASARR Level I Screening and confirmed that Resident 10's PASARR Level I Screening should have indicated she had a serious diagnosed mental disorder such as schizophrenia. Review of facility's policy and procedure (P&P) entitled admission Criteria dated 2001, the P&P indicated, .9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that meet professional standards of quality for two of 14 sampled residents (Residents 4 and Resident 1) when: 1. For Resident 4, the facility staff did not document the apical pulse (the pulse that is felt at the bottom of the heart) before administering Digoxin (a medication used to treat certain heart conditions); and 2. Resident 1 was given the medication Carvedilol (used to treat high blood pressure) when her diastolic blood pressure (the bottom number in a blood pressure reading, representing the pressure in your arteries when your heart is at rest between beats) was low (a diastolic pressure reading below 60 is considered low) at 50 mmhg (millimeters of mercury, a unit of measurement). These failures had the potential to compromise the residents' care and could cause health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for one of 14 residents (15) when Resident 15 did not receive weekly weight and one-to-one feeding assistance with all meals as ordered by the physician. This failure had the potential to negatively affect the resident's nutritional status, health, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to conduct performance review at least once every 12 months for one of 4 certified nursing assistants (CNA F) and one of two licensed vocational nurses (LVN G). This failure resulted in unidentified training needed for the CNA and the LVN to improve their skills in resident care every year.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate record of medication disposition when number of counted Lorazepam (medication that helps calm the brain and nervous system) tablets for destruction was not correctly documented. This failure had the potential for misuse or diversion of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 6 residents (25 and 79) were free from unnecessary medications when Resident 25 and Resident 79 received apixaban (a blood thinner to prevent blood clots) but were not monitored for the side effects and not care-planned on the use of the medication. This failure had the potential for the residents to experience unrecognized adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 8% when two medication errors occurred out of 25 opportunities during medication administration for 1 out of seven residents (Residents 129) when Resident 129's medications, Metformin (medication primarily used to a condition where the body doesn't use insulin properly to control blood sugar levels) and Insulin Lispro (a rapid-acting form of insulin used for the treatment of high blood sugar) were not given according to the Physician's Orders. The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when an opened lorazepam oral concentrate (medication that helps calm the brain and nervous system) was found inside the refrigerator without an open-date label. The deficient practice had a potential for residents to receive medications with unsafe and reduced potency which could lead to unsafe and ineffective medications for the residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent (permission or agreement from someone having authority or power) for Coronavirus Disease (COVID-19, a mild to severe respiratory illness that is airborne and is spread from person to person or by contact with infectious material such as respiratory droplets in the air and to a lesser degree on high touch surfaces in the environment) vaccination for one of 5 residents (4). This failure had the potential to result in Resident 4's responsible party (RP, the party responsible to making health care decisions when the principal party is unable to make) not being aware of the risks and benefits of COVID-19 vaccine, and therefore unable to make an informed healthcare decision regarding the vaccine.

Inspectors wroteBased on observation, interview and record review, the following multi-resident rooms provided less than 80 square feet per resident:

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to prevent one of two residents (Resident 1) who were at risk for elopement from leaving the facility without staffs' knowledge and permission when Resident 1's wander guard (device used to keep track of residents), was not checked for functionality and staff did not provide Resident 1 with supervision or assistance. These failures compromised Resident 1's safety, as she was found outside of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) with the resident, or resident representative, document the use of alternatives prior to installation of bed rails for three of 23 residents (Resident 23, Resident 25, and Resident 131), and obtain informed consent prior to the use of bed rails for three of 23 residents (Resident 4, Resident 6, and Resident 18). These failures had the potential to put the residents at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanitary food service operations were carried out according to standards of practice when: 1. A wet rice cooker pot was stored in the rice cooker without being air dried; and 2. The dry storage room bottom shelf was under six inches (a unit of length) off the floor. These failures had the potential to expose 27of 28 residents to harmful contaminants that could cause foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose the garbage and did not follow the facility's policy and procedures (P&P) for Covering receptacles when one of two dumpsters did not have lids closed properly. This failure had the potential to attract pests and rodents which could lead to unsanitary conditions and spread of disease.

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal vaccine (vaccine to prevent bacterial pneumonia [infection of the lungs]) up to date for 10 of 15 sampled residents (Resident 3, 4, 9, 11, 12, 13, 16, 17, 19, and 27) per the Centers for Disease Control and Prevention (CDC)'s pneumococcal vaccine schedule guidelines. This failure had the potential to place residents at a high risk of acquiring and transmitting pneumonia in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respect and dignity for two of 12 sampled residents (Resident 17 & Resident 19) during mealtime. These failures had the potential to negatively affect Resident 17 & Resident 19's emotional health.

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a financial liability notice) for one of three sampled residents (Resident 27). This failure could lead the resident unknowingly assume financial liability for receiving services that were not covered by Medicare (federal health insurance for anyone age [AGE] and older, and some people under 65 with certain disabilities) .

Inspectors wroteBased on interview and record review, the facility failed complete annual performance reviews for 2 of 4 sampled staff (Certified Nursing Assistant [CNA] E and CNA C). These failures had the potential to negatively affect patient care.

Inspectors wroteBased on observation, interview and record review, the facility failed to store temperature sensitive medications appropriately. This failure had the potential for residents to receive medications with limited effectiveness.

Inspectors wroteBased on observation, interview and record review, the facility failed to document repositioning for one out of 12 sampled residents (Resident 3) while in bed. This failure had the potential to result in inaccurate provision of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement proper infection control measures when: 1. The Infection Preventionist (IP) did not put on a pair of disposable gloves prior to handling a urine bag. 2. Licensed Vocational Nurse (LVN) G did not perform hand hygiene during medication administration. These failures had the potential to result in spread of infection and compromise the health and safety of the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides (Certified Nursing Assistants: CNAs) received 12 hours of annual in-service which included dementia management and abuse prevention training for a census of 28 when documentation of the nurse aide in-services could not be provided for 2 of 4 sampled staff. This failure had the potential to affect the quality of care and services provided to the residents.

Inspectors wroteBased on observation, interview and record review, the following multi-resident rooms provided less than 80 square feet per resident:

Inspectors wroteBased on interview and record review the facility failed to exercise the resident's right as a resident of the facility for one out of three resident (Resident 1) when Resident 1 was not allowed to leave out on pass to get her Covid-19 (Covid-19: a sickness caused by virus called severe acute respiratory syndrome coronavirus 2) booster vaccine (lessens the severity of Covid-19 by teaching the person's immune system to recognize and fight the virus that causes the disease) outside the facility. This failure had the potential to effect on health and well-being to Resident 1

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for 8 consecutive hours, for seven days (7/15/23, 7/16/23, 7/22/23, 7/30/23, 8/13/23, 8/19/23, and 8/20/23) out of 62 sampled days. This failure had the potential to negatively affect all 27 residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food safety when: 1. Time Temperature Control for Safety Foods (TCS=food requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation) were above 41°F (°F, a temperature scale) in the Residents' refrigerator, and refrigerator and freezer temperatures were not monitored, 2. Residents' food items were not monitored for expiration dates, 3. Staff did not perform proper hand hygiene while dishwashing, 4. A can opener was not kept in sanitary condition, 5. Freezer gaskets had blackish substance in the crevices, 6. Supply closet had staff's personal belongings with the cleaning equipment, and food equipment; and 7. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services for effective communication when the facility did not provide language assistance or other communication aid for four of five sampled residents (Residents 6, 24, 127 and 128) with language barrier (speaking in foreign language). This failure had the potential to affect the psychosocial well-being of the resident and a decline in the activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 12 sampled residents (Resident 11, 2, and 128) received the appropriate care and services when: 1. For Resident 11, licensed vocational nurse A (LVN A) did not administer Metformin (a drug that helps to control the amount of glucose (sugar) in your blood) as ordered; 2. For Resident 2, facility staff did not follow physician's order of administering resident's tube feeding (giving medicines and liquids through a small tube placed through the nose or mouth into the stomach or small intestine) and did not monitor signs and symptoms while on anticoagulant (medicines that help prevent blood clots) medication; and 3. For Resident 128, facility staff did not properly monitor resident's intravenous (IV, into or within a vein) therapy. [...]

Inspectors wroteBased on observation, interview, and record review , the facility staff failed to ensure drugs and biologicals were safely stored and discarded per facility's policy and manufacturer's recommendations when; 1. a multi-dose vial of Tuberculin solution (injected under the skin to aid diagnosis of tuberculosis (infectious disease that usually affects the lungs) had no opened date; 2. one eyedrop and one insulin (medication to treat high blood sugar) vial for Resident 24 and an insulin pen for Resident 11 was being used past the discard date; and controlled medications (controlled by the government because it may be abused or cause addiction) for 5 discharged residents were not removed from the medication cart in a timely manner. These failures had the potential for residents to receive medications with reduced potency and unsafe access to controlled medications in the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the planned menu was followed when 1. Three of three residents (Residents 126, 20, and 76) on renal diets, (diets that are designed for people with kidney function that slowly gets worse with time) were served potatoes and chocolate mousse. 2. Four of four residents (Residents 128,13, 3, and 12) on puree diets (texture modified diets for people with chewing or swallowing difficulties) when they were served pureed foods different from regular foods. 3. Ketchup was not served according to the menu. These failures had the potential to result in not meeting the nutritional needs thus further compromising the nutritional status of these residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Escitalopram Oxalate (a psychotropic medication used to treat depression and certain anxiety disorders) was administered with consent of Resident 25. This failure had the potential of not honoring resident's rights to be informed about his treatment. Review of the clinical record indicated Resident 25 was admitted to the facility on [DATE] with diagnosis of multiple sclerosis (chronic disease affecting the central nervous system, depression (a mental health problem that involves a low mood and a loss of interest in activities). Review of Resident 25's Order Summary Report, indicated the physician order dated on 6/13/2022 to give Escitalopram Oxalate 20 milligrams (mg, unit of measurement) one tablet by mouth once a day for major depression. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide to one of 12 sampled residents (Resident 25) his preferred foreign television channel. This failure had the potential to affect the physical and mental well-being of Resident 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nephrostomy tube (a catheter that's inserted through your skin and into your kidney. The tube helps to drain urine from your body) care to one of 12 sampled residents (Resident 25). This failure had the potential to affect the health and well-being of Resident 25.

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to provide foods at an appetizing temperature for three of 24 residents (Resident 21, 11, 15) receiving food from the kitchen. This failure had the potential to result in decreased intake thus further compromising the nutritional status of these residents.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to provide a therapeutic diet as prescribed by a physician for one resident (Resident 17) out of 24 residents when Resident 17 received regular texture meat instead of Mechanical soft (a modified diet that restricts foods that are difficult to chew or swallow). This failure had the potential to result in the resident not being able to chew the food possibly leading to choking.

Inspectors wroteBased on observation, interview and facility's document review, the facility failed to implement infection control measures when: 1. The certified nurse assistant H (CNA H) did not perform hand hygiene after touching dirty carts and placed a clean bag of towels and gowns on top of Resident 126's four wheeled walker; 2. The Infection Preventionist (IP) did not perform hand hygiene prior to donning (putting on) a pair of gloves to flush a peripheral intravenous catheter (a thin, flexible tube inserted into a vein); 3. The licensed vocational nurse A (LVN A) did not perform hand hygiene in between tasks during Resident 126's wound care; and 4. The licensed vocational nurse A (LVN A) did not perform hand hygiene in between tasks and pulled out a handful of gloves for use during Resident 24's wound care. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure to ensure all staff were fully vaccinated for COVID-19 (a new infectious viral disease that can cause respiratory illness) when there were no evidence of proof of vaccination or medical waiver for one of 43 staff (BOM-business office manager). As a result, the facility's COVID-19 staff vaccination rate was 97.67% on 7/22/2022. This failure had the potential to spread COVID-19 infection to staff, residents, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and functional environment for staff when a kitchen cabinet door was broken at the hinge. This failure could result an injury to the staff when working in the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment was free of pests as evidenced by flying insects seen in the kitchen, and conference room. This failure had the potential to cause a health hazard to the residents and staff.

Inspectors wroteBased on observation, interview and record review, the following multi-resident rooms provided less than 80 square feet per resident.