San Jose Healthcare & Wellness Center

Inspectors wroteBased on interview and record review, the facility failed to establish and communicate which licensed nurse was responsible for providing care to one of three sampled residents (Resident 1) on the evening shift (3:00 p.m. to 11:00 p.m.) of 4/9/25. This failure resulted in Resident 1 not receiving scheduled medications in a timely manner, and had the potential to result in other care needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for six of 11 residents (31, 33, 35, 37, 42, and 49) when: 1. Residents 31, 33, and 35 did not have care plan for siderails; 2. Residents 42 and 49 did not have a physician's order for the use of siderails and care plan for siderails; and 3. Resident 37 did not have a consent and a physician's order for the use of siderails, and care plan for siderails. These failures had the potential to place the residents at risk of entrapment and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when kitchen staff did not correctly demonstrate how to test the dish machine sanitizer. This failure had the potential to place 51 residents who consumed food from the kitchen at risk for exposure to contaminants in food that may lead to food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food preparation equipment and food storage methods, according to standards of practice and facility policy when: 1. Foods were stored unlabeled and/or past used-by date; and 2. Sink drainage pipe with buildup within the inner lining. These failures had the potential for food contamination, resulting in food borne illnesses for 51 residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat the residents with dignity for one of 14 residents (31) when licensed vocational nurse A (LVN A) opened Resident 31's room door without covering her while her back and buttocks were exposed. This failure had the potential to cause embarrassment and feelings of low self-esteem (unhappy and thinking negatively about yourself) for the resident.

Inspectors wroteBased on interview and record review, the facility failed to properly obtain informed consent (permission granted in the knowledge of the possible consequences) for psychotropic medications (medications capable of affecting the mind, emotions and behavior) for three (Resident 20, Resident 4, and Resident 28) out of 14 residents. This failure had the potential to compromise the right of the residents or responsible parties (persons designated to make decisions of behalf of the residents) to be fully informed regarding care and treatment in order to make health care decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left unattended at the bedside for one of 14 sampled residents (Resident 4). Resident 4 was not approved to self-administer medications. This deficient practice placed Resident 4 and other residents at risk for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for three of 14 residents (3, 21, and 23) when: 1. Resident 3 was not served yogurt, tofu, orange, tangerine with his meals as ordered by the physician; 2. For Resident 21, rolled towels to his bilateral (right and left sides of the body) hands and offloading boots to his bilateral lower extremities were not applied as ordered by the physician; and 3. Certified nursing assistant C (CNA C) did not know about her resident, Resident 23. These failures had the potential to affect the residents' care and could jeopardize their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were fully administered as prescribed for one of 4 residents (Resident 21) observed during medication pass administration. This failure placed Resident 21 at risk for ineffective treatment and potential health complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and label medications and biologicals according to manufacturer instructions and facility policy. These failures had the potential for residents to receive incorrect or unsafe medications.

Inspectors wroteBased on interview and record review, the facility failed to explain the arbitration agreement (a contract requires that person who signed it resolve disputes by a neutral third party, rather than in court before a judge and/or jury) which Resident 23 and Resident 31 signed during their admission to the facility. This failure resulted in Resident 23 and Resident 31 signing the facility's arbitration agreement without their full understanding of the same.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 10 bedrooms measured at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident 14) out of 14 sampled residents was free from abuse when staff shouted at and did not acknowledge Resident 14's statement for hunger. This failure had the potential to impact the physical and mental well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) received medications as ordered by the physician. This failure had the potential to compromise the resident's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record was complete and accurate for one of three sampled residents (Resident 1) when there was no documentation that the nurse notified Resident 1's physician of multiple medications that were not administered. This failure had the potential to compromise the facility's ability to track and communicate care relevant to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards of practice for two of three sampled residents (Resident 1 and 2) when: 1. Staff did not complete an SBAR (situation, background, assessment, recommendation, a communication tool) and did not notify the physician and the responsible party (RP, person designated to make decisions on behalf of a resident) when an altercation occurred between Resident 1 and Resident 2; 2. Licensed nurse did not do a skin assessment for Resident 1 when Resident 2 threw coffee on Resident 1; 3. Licensed nurses did not put Resident 1 and Resident 2 on alert charting (nurses on each shift closely monitor and document in the medical record for 72 hours about a specific condition) when an altercation between Resident 1 and Resident 2 occurred; 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Ombudsman (resident advocate) was notified of discharges for three of three residents (Residents 1, 2, and 3). This failure had the potential to result in the residents not having someone to advocate for their admission, transfer, and discharge rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Oxygen Therapy policy for two of three sampled residents (Residents 4 and 5) who used oxygen when: 1. Resident 4's nasal cannula (flexible tubing inserted into the nostrils and attached to an oxygen source) was unlabeled and undated; and 2. There was no No Smoking sign posted for Resident 5's room. These failures had the potential to compromise the residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure complete records for controlled medications (those with high potential for abuse and addiction) when controlled medication use audit for three of six residents (Residents 13, 43, and 153) were not reconciled. The medications were signed out of the Individual Narcotic Record count sheet (an inventory sheet that keeps record of the usage of controlled medications); however, they were not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. This failure had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored in accordance to professional standards of food safety when: 1. Outdated graham cracker crumbs in a plastic container was stored in an active use area of the dry storage; 2. An ice chest containing ice was stored on the floor. These failures had the potential to cause foodborne illness for residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 34) received a replacement of her personal belongings when her bilateral (affecting both sides) hearing aids (small, wearable electronic device to facilitate better communication) were missing since the end of December 2022. This deficient practice resulted in Resident 34 to be without hearing aids for over nine months.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician's orders when a licensed vocational nurse (LVN F) did not administer a medication to Resident 152 according to the physician's order for it. This failure resulted in Resident 152 to not receive the physician's ordered medication as prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 34) received assistive devices when when her bilateral (affecting both sides) hearing aids (small, wearable electronic device to facilitate better communication) were missing since the end of December 2022. This deficient practice resulted in Resident 34 to be without hearing aids for over nine months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 16), was provided Restorative Nursing Assistance (RNA; restorative care for individuals recovering from illnesses or injuries) services as ordered. This failed practice could result in decreases in mobility and complications for residents requiring RNA services.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review for one of three certified nursing assistants (CNA) at least once every 12 months for CNA E. This failure resulted in a lack of evaluation and feedback related to CNA E's performance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 10 bedrooms measured at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to transfer the resident's body to the referred mortuary (a funeral home, where dead bodies are kept before burial or cremation) within four hours after Resident 1 expired at the facility. This failure has caused significant emotional distress for three of three sampled residents (Resident 2, 3, and 4).

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed for four residents (Residents #1, 14, 20, 33) on Regular Carbohydrate Controlled (CCHO) diets (diets designed for people with Diabetes to assist in keeping blood sugars within normal range). This failure had the potential to result in not meeting the nutritional needs thus further compromising the nutritional status of the residents.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety when: 1. Nursing refrigerators were out of temperature range two times in a week, 2. An air gap was not present in the food preparation sink, and 3. Food service equipment was stored wet. These failures had the potential to cause the growth of microorganisms which could cause foodborne illness or cross contaminate food (cross contamination occurs when unclean surfaces or utensils spread germs to food and can potentially cause foodborne illness) for the 47 residents eating at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control procedures when: 1. Resident 3's oxygen nasal cannula (a device consisting a lightweight tube, split on one end into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows) was lying on her bed and not covered; 2. Certified nursing assistant J (CNA J) did not sanitize or wash her hands after touching the curtain and before feeding Resident 43; 3. Resident 43's syringe which was used to flush and administer the medications through his gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach; it can be used to give drugs and liquids, including liquid food, to the resident) was not changed daily; 4. Staff did not wear a gown while providing direct resident care in the yellow zone; 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR, screening for individuals with a mental disorder and individuals with intellectual disability) screening document was accurately completed for two of two residents (39 and 43). This failure had the potential for mentally ill residents not to receive the required care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the risk for fall care plan was implemented for one of two residents (43) by not placing the landing pad on the right side of Resident 43's bed for his safety. This failure had the potential for Resident 43 to sustain injury if he fell from his bed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plan was revised for one of three residents reviewed (Resident 3), to include new intervention/s to prevent recurrence of elopement (wandering). This failure had the potential to present imminent threat to resident's safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received the necessary care and services to attain and/or maintain their highest practicable well-being for two of twelve sampled residents (39 and 43) when: 1. Licensed nurses did not hold midodrine (used to treat low blood pressure) 10 milligrams (mg, a metric unit of mass) as ordered for Resident 39, when her systolic blood pressure (SBP, the pressure in the arteries when the heart beats) was higher than 130 millimeters of mercury (mmHg, a measurement of pressure); and 2. Physician's laboratory orders for Resident 43 were not done: [...]

Inspectors wroteBased on interview, and record review, the facility failed to maintain a consistent process of drug reconciliation (maintenance of an accurate count) when incoming and outgoing licensed nurses did not consistently sign the controlled drug count document at change of shift, 13 times in 6 weeks (10/24/21 - 12/6/21) for one of two medication carts. This failure had the potential to result in the delay of identification of medication discrepancy (the difference in the actual count versus the recorded amount) and possible inappropriate use of controlled narcotic (drugs used to reduce pain, induce sleep and may alter mood or behavior) medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) recommendations were acted upon for one of 12 sampled residents (39) when the CP indicated hemoglobin A1c (HbA1c, a test measures the amount of blood sugar attached to part of the red blood cells that carries oxygen from the lungs to the rest of the body) and electrocardiogram (EKG, a test measures electrical signals in the heart; an abnormal EKG can be a sign of heart disease or damage) for Resident 39, and the facility did not present these recommendations to the physician. This failure had the potential for Resident 39 to receive unnecessary medication and to suffer unnecessary adverse side effects that could negatively impact her physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility had a 5.56% medication error rate when two medication errors out of 36 opportunities were observed during medication passes for two residents (Residents 2 and 32). These failures had the potential to compromise the residents' medical health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication and biologicals were stored and labeled appropriately when undated medications and an expired medication were found in the medication carts; and internal and external medications were not stored separately. These failures had the potential for residents to receive expired, incorrect, and unsafe medications.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure one kitchen staff had appropriate competencies when the staff did not know the correct final temperature for cooked chicken and did not calibrate three thermometers correctly. These failures had the potential to place the 47 residents who received food prepared in the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ten bedrooms measured at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive.