San Jose Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 12 residents (Resident #1, #19, #21, and #25) reviewed for care plans:1. The facility failed to ensure Resident #1's care plan reflected the resident was at risk for pressure ulcers and used heel protectors.2. The facility failed to ensure Resident #19's care plan reflected the resident was treated with antipsychotic medications.3. The facility failed to ensure Resident #21's care plan reflected the resident was treated with antipsychotic medications.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 3 carts (west ramp medication aide cart) reviewed for pharmacy services. The facility failed to ensure the controlled substance reconciliation log was signed for accuracy of medication quantities during shift change. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 Kitchen reviewed for food safety requirements.1. The facility failed to label and date half a tomato wrapped in clear wrap in the reach in refrigerator; the Dietary Supervisor's hair was not completely covered by a hair restraint, and the facility failed to provide a readily accessible hands-free covered trash receptacle in the kitchen. Kitchen staff were required to touch the trash can lid to dispose of waste.2. The facility failed to label and date two bundles of green leaf lettuce wrapped in plastic, one opened gallon container of milk, and one bin of tomatoes, bell peppers, and celery stored in the refrigerator; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 3 of 12 residents (Resident #1, #21, and #37) reviewed for accuracy of records:1. The facility failed to document in Resident #1's treatment records the use of heel protectors at bedtime every evening shift per physician's orders for April 2026 on 4/9/26, and 4/14 - 4/30/2026, and the entire month of May 2026.2. The facility failed to document the diagnoses for use of antipsychotic medications on Resident #21's admission sheet.3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 residents reviewed for dignity. The facility failed to ensure CNA E did not feed Resident #1 while standing over him. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 6 residents (Resident #17) reviewed for accidents and hazards:The facility failed to ensure Resident #17 did not have disposable razors, a pair of scissors, a can of air freshener, and a one-pound container of disinfectant wipes in her room. These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to post the nurse staffing data daily at the beginning of each shift for 1 of 4 days (6/26/26) reviewed for nursing staffing:The daily posted nurse staffing data had the previous day's nurse staffing data for 6/25/26, instead of the 6/26/26 nurse staffing data. This deficient practice could affect all residents and could result in residents and visitors being unaware of staffing levels in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 trash disposal areas that was reviewed for disposal of garbage. The dumpster drainage hole did not have a plug. This failure could place residents at risk for exposure to germs and diseases carried by pests and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 1 Laundry Room reviewed for infection control:The facility failed to ensure the Laundry Room did not have personal employee food items on the clean folding table and clean laundered resident linens were stored uncovered on the clean storage shelf. These failures could place residents at risk for cross-contamination and infection and could result in illness due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure bedrooms measured at least 80 square feet per resident in multiple resident bedrooms for 16 of 32 double occupancy resident rooms (Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31). Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 did not have the required 80 square feet per resident. This deficient practice could place residents at risk of inadequate space for activities of daily living in their rooms.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinence care. When CNA-A was providing incontinent care to Resident #1 on 06/18/2026, CNA-A did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region) and left buttock area. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to revise residents comprehensive care plan for 4 of 12 Residents (Resident #4, Resident #19, Resident #27 and Resident #30) reviewed for Comprehensive Resident Centered Care Plan. 1. The facility failed to revise Resident #4's Care Plan for the use of 1/2 SR and to provide timeframe's for the review period. 2. The facility failed to revise Resident #19's care plan for diet and care plan interventions after weight loss. 3. The facility failed to revise Resident #27's Care Plan for the use of 1/2 SR. 4. The facility failed to revise Resident #30's care plan interventions for physical restraint. These deficient practices could affect any resident and could contribute to resident's not receiving needed care and services as identified in the residents medical record and or MDS.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail and review the risks and benefits of bed rails with the resident or resident representative for 4 of 7 Residents (Resident #4, Resident #14, Resident #17 and Resident #27) whose records were reviewed. 1. Nursing staff failed to attempt to use the least restrictive alternatives before using a 1/2 SR for Resident #4. They also failed to indicate the benefits and risks for using a 1/2 SR or to assess Resident #4 for its use. 2. Nursing staff failed to obtain a consent for the use of 1/2 SR for Resident #14 and failed to assess her once a 1/2 SR was implemented. 3. Nursing staff failed to obtain a consent or to assess Resident #17 for the use of 1/2 SR. 4. [...]

Inspectors wroteBased on interview and record review the facility based on a comprehensive assessment of a resident failed to ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 of 7 Residents (Resident #4 and Resident #35) whose records were reviewed for psychotropic medications. 1. Nursing staff failed to ensure Resident #4's informed consent for Haldol (anti-psychotic medication) included the psychiatric condition, assessment for the use of the medication, the risks and benefits and the need for the use of the medication. 2. Nursing staff failed to ensure Resident #35's informed consent for Seroquel (antipsychotic medication), failed to identify the condition being treated and the potential beneficial side effects of the use of the medication. [...]

Inspectors wroteBased on observation, interview and record review the menus were not followed, were not updated periodically and were not reviewed by the facility's dietician in 1 of 1 kitchen. 1. Dietary Staff failed to follow the menu on 04/08/25 for 1 of 1 meal; lunch meal. 2. The facility failed to ensure the Dietician reviewed the updated facility menus at the time the menus were made available. for about 5 months These deficient practices could affect all residents and could contribute to residents not being satisfied with their meal options.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to serve the cold chicken penne pasta salad and the mechanical vegetable mixture at 41 F or below for the evening meal service. This failure could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 6 residents (Resident #26), reviewed for resident rights. Resident #26's call light was on the floor and not within reach of the resident. This failure could place residents at risk of not receiving needed care and services in a timely manner.

Inspectors wroteBased on observations and interviews the facility failed to ensure each resident has a right to personal privacy and confidentiality of their personal and medical records. The facility failed to ensure the MAR binder (a binder with a list of residents' prescribed medications and when the medications were administered) on the west wing medication cart was kept confidential when it was left open and facing the hallway unattended while visitors and staff walked by. This could place residents at risk for private health information being viewed by unauthorized individuals.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 7 Residents (Resident #17) who were observed for wheelchair use. The facility failed to ensure Resident #17's wheelchair armrest were in good repair. Both armrests were cracked and torn. This deficient practice could affect residents who used a wheelchair and could contribute to injuries; skin tears.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident was free from physical restraints imposed for purposes of convenience that are not required to treat the resident's medical symptoms for the least amount of time and document ongoing re-evaluation of the need for restraints for 4 of 4 days during the survey period (4/8/25, 4/9/25, 4/10/25, and 4/11/25) reviewed for freedom from abuse. Resident #30 was seated in a Geri-chair with a tray table on 4/8/25, 4/9/25, 4/10/25, and 4/11/25 . The tray table was always present when the resident was out of bed and not removed for meals, or activities. And there was no documentation of ongoing re-evaluation of the need for restraints. [...]

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program for residents with newly evident or possible serious mental disorder for 1 of 4 Residents (Resident #4) whose records were reviewed. The facility failed to refer Resident #4 for Level I screening after being diagnosed with a mental disorder. This deficient practice could affect residents with a mental diagnosis and can result in residents not receiving services as identified by PASARR.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene for 1 of 7 Residents (Resident #35) for Quality of Life. The facility failed to assist Resident #35 with washing her face and brushing her teeth. This deficient practice could affect residents who were unable to carry out activities of daily living and result in resident's being dissatisfied and having poor self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 residents (Resident #26), reviewed for quality of care. Resident #26's nebulizer mask was uncovered and the elastic that holds it on to the resident's face was stretched around the uncovered nebulizer machine. The nebulizer mask had an unknown white substance on it. This failure could place residents at risk of cross contamination and respiratory illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented, and failed to safeguard medical record information against loss, destruction, or unauthorized use for 1 of 6 residents (Resident #19) reviewed for administration. Resident #19's nutrition assessment form had the correct resident name but the wrong admission date, wrong date of birth , the wrong height and ideal body weight range. This could place residents at risk for inaccurate health records and incorrect plans of action.

Inspectors wroteBased on interview and record review the facility failed to ensure the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services and failed to have a communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day for 1 of 3 residents (Resident #88), reviewed for hospice services. Resident #88's hospice binder and medical record had no hospice visit nursing notes and the facility staff nurses were not aware the hospice documentation was needed as part of the medical record. This failure could place residents at risk of decreased continuity of care, not receiving necessary care and services in a timely manner.

Inspectors wroteBased on interviews and record review, the facility failed to provide a minimum of 80 square feet per resident in 16 of 32 double occupancy resident rooms (Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31), in that: Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 did not have the required 80 square feet per resident. This deficient practice could place residents at risk of problems in their activities of daily living.

Inspectors wroteBased on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 5 staff (NA A and NA B) whose records were reviewed. The facility failed to ensure NA A and NA B were screened through the EMR and NAR registry to ensure they were employable. These deficient practices could affect any resident and contribute to resident abuse, neglect, exploitation and misappropriation of resident property.

Inspectors wroteBased on interview and record review the facility failed to ensure before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements for 2 of 3 Staff (NA A and NA B) whose records were reviewed. The facility failed to ensure NA A and NA B completed a nurse aide program and received their certification. This deficient practice could affect all residents and result in staff not being eligible to provide direct care to residents.

Inspectors wroteBased on interview and record review the facility failed to provide training to their staff that at a minimum educated these staff on procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property for 2 of 5 staff (NA A and NA B) whose records were reviewed for abuse training. Staff NA A and NA B did not have their training for abuse or neglect for the year 2024. This deficient practice could affect any resident and contribute to resident abuse and or neglect.

Inspectors wroteBased on interviews and record review the facility failed to ensure all resident assessments completed within the previous 15 months in the resident's active record were maintained in the resident's active medical records for 6 of 6 residents reviewed for MDS assessments. (Resident #1, Resident #10, Resident #13, Resident #18, Resident # 21, and Resident #35) in that -MDS assessments for Resident #1, Resident #10, Resident #13, Resident #18, Resident # 21, and Resident #35 were not accessible to staff and ready to review, when the DON/Owner was not on site and able to unlock the cabinet in which all resident MDS assessments were stored. These failures affected 6 residents and placed them at risk of not having their assessments available for review.

Inspectors wroteBased on observations and interviews the facility failed to provide a safe functional, sanitary, and comfortable environment for residents, staff, and the public. The facility failed to ensure good general safety precautions were in place in one outside building, 39.11 feet away from the nursing facility; where food was stored, staff complete laundry services for residents, and facility maintenance items were stored. Findings Included: During an observation on 03/06/2024 at approximately 5:45 p.m., the following observations were made: A building adjacent to the main nursing facility building was used to house the laundry room, food pantry, and the maintenance room. The maintenance room and laundry room were separated by a cinder brick wall, the pantry and the maintenance room were separated by a gypsum wall. The building measured at approximately 39.11 feet away from the main building. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the assessments accurately reflected the resident's status for 1 of 3 residents (Resident #35) reviewed for assessments: The facility reported diagnoses included depression, psychotic disorder( serious illness that affects the mind and make it hard for someone to think clearly make good judgements), schizophrenia (mental disorder characterized by reoccurring episodes of psychosis that are corrected with a general misperception of reality), and post-traumatic stress disorder( a mental health condition that is triggered by a traumatic event) on Resident #35's most recent MDS assessment, (dated 01/04/2024). No medical record available in the resident's chart or that the DON/Owner could provide supported the resident having been given those diagnoses at that time or historically. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #4 and resident # 141) of 8 residents reviewed for care plans. Resident #4 had no care plan in his chart. Resident #141's care plan was incomplete and only had two pages in the care plan.

Inspectors wroteBased on interviews and record review, the facility failed to provide a minimum of 80 square feet per resident in 16 of 32 double occupancy resident rooms (Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31), in that: Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 did not have the required 80 square feet per resident. This deficient practice could place residents at risk of problems in their activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility for 1 of 2 (Resident #1) residents reviewed for transfer and discharged rights. The facility failed to readmit Resident #1 after an acute care hospital stay resulting in Resident #1 not being permitted to stay in the facility pending placement or appeal. This deficient practice could place residents residing in the facility at risk of not being able to remain at the facility, resulting in violation of their rights.

Inspectors wroteBased on interview and record review the facility failed to ensure before transferring or discharging a resident, the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged for 1 of 2 residents (Resident #1) reviewed for discharge requirement. The facility refused to accept Resident #1 back on 11/25/2023 after emergently discharging Resident #1 to acute care (on 11/23/2023) for attacking an LVN and CNA. Resident #1's Responsible Party was not given a 30-day discharge notice when the facility refused to readmit Resident #1 from the acute care hospital on [DATE]. These failures could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options and appeal process. Findings Include: [...]

Inspectors wroteBased on interview and record review the facility failed to establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave for 1 of 2 residents (Resident #1) reviewed for discharge requirement, in that: 1. The facility failed and refused to readmit Resident #1 from the hospital where he was transferred for evaluation and treatment. 2. The facility failed to give Resident #1 or his RP a 30 day discharge notice. These deficient practices could affect residents discharged from the facility and their ability to return to the facility. Findings Include: Record review of Resident #1's admission record, dated 07/18/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure it received registry verification for 1 (CNA A) of 4 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide in that: The facility failed to ensure CNA A had a current nurse aide certification while employed at the facility, while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care.