Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Empress Care Center, Llc during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete required bed rail entrapment assessments for all residents using bed rails, failed to attempt alternative interventions before implementing bed rails for several residents, and did not include a specific care plan for bed rail use for one resident. Interviews with the DON and MD confirmed a lack of coordination and documentation regarding bed rail safety and assessment.
Two residents reported that their meals were bland, and test tray observations confirmed that both regular and pureed foods lacked flavor. The cook and registered dietitian acknowledged the issue, and it was observed that foods were held in heated ovens for extended periods before service, contrary to facility policy requiring minimal holding time to preserve taste and nutrients.
Surveyors identified unsanitary cooking equipment, improper storage of corrosive chemicals near food utensils, an ice scoop left in an accessible area risking contamination, and a dietary aide failing to follow hand hygiene protocols during meal tray preparation. These deficiencies were observed during food service to forty-nine residents.
The administrator worked as the facility's ADM after his NHA license expired, without the required supervision by a licensed NHA for more than 10 days, in violation of state licensure requirements.
The facility did not follow its policy to offer or assist with advance directives for several residents, as confirmed by review of clinical records and interviews with the SSD and DON. No evidence was found that residents without advance directives were provided assistance or scheduled visits with an Ombudsman or patient advocate, as required by facility policy.
Surveyors identified multiple infection control lapses, including staff failing to perform hand hygiene before resident care, improper glove use, undated and unclean oxygen equipment for residents with COPD, unlabeled personal care items in shared bathrooms, and missing PPE disposal receptacles in rooms with enhanced barrier precautions. Staff were also observed wearing face masks incorrectly, all contrary to facility policies and infection prevention protocols.
Two dryers were found operating with lint filters covered in a thick layer of lint, as staff failed to check and clean the filters before use, contrary to facility policy. Both the staff member and supervisor confirmed the oversight during interviews.
Two residents did not have comprehensive care plans addressing their clinical needs: one resident receiving continuous oxygen therapy lacked a care plan for oxygen use, and another resident with significant weight loss over six months had no care plan to address nutritional needs. These omissions were confirmed through record review and staff interviews, despite facility policy requiring individualized, measurable care plans.
Licensed nurses administered hydrocodone-acetaminophen to a resident for moderate pain, despite physician orders specifying use only for severe pain. The DON confirmed that the medication was given for pain levels below the ordered threshold, and the facility's policy required following the medication regimen as ordered.
Two residents with COPD did not receive oxygen therapy at the flow rates ordered by their physicians, as both were observed receiving less oxygen than prescribed. An LVN confirmed the discrepancies during interviews, and facility policy requires oxygen to be administered as ordered by the physician.
A resident with anemia was given ferrous sulfate and calcium at the same time each day, despite orders and pharmacy guidelines indicating these medications should be administered separately to avoid a significant drug-drug interaction that reduces iron absorption. The facility's pharmacy policy required screening for such interactions, but this was not followed.
A consultant pharmacist did not identify or report a high-dose vitamin D3 order for a resident, resulting in the resident receiving an excessive dose for over ten months. In a separate case, a pharmacist’s recommendation to review the continued need for omeprazole was not presented to the physician, and no follow-up occurred. These failures show lapses in the facility’s medication regimen review and follow-up processes.
A facility failed to report an alleged abuse incident involving a resident with dementia immediately, as required by state law. A CNA witnessed another CNA shoving food into the resident's mouth and pulling their ear but delayed reporting due to intimidation. The incident was reported to the DON two days later, who then informed the appropriate authorities. The facility's policy requires immediate reporting of abuse allegations, which was not adhered to in this case.
Failure to Complete Bed Rail Assessments, Attempt Alternatives, and Care Plan for Bed Rail Use
Penalty
Summary
The facility failed to complete required bed rail entrapment assessments for all 48 residents who used bed rails. Observations revealed that multiple residents had bed rails in use, but their clinical records did not contain documentation of entrapment risk assessments. Interviews with the maintenance director (MD) and director of nursing (DON) confirmed that there was no coordination between departments to assess the risks of entrapment or to ensure that bed rails were appropriate for the size and weight of each resident. The MD stated that bed rails were installed or removed based on nursing staff requests and resident needs, but no adjustments were made according to resident size, and no documentation of safety monitoring was provided. Additionally, the facility did not attempt alternative measures before implementing bed rails for six residents. Review of physical restraint assessments for these residents indicated that alternatives were not considered or documented prior to the use of bed rails. The DON confirmed that nursing staff did not complete assessments for alternative interventions before starting bed rail use for these residents. Furthermore, one resident who had an order for bilateral half side rails did not have a separate and specific care plan addressing the use of side rails. The DON verified that this resident's care plan did not include information about the use of side rails and acknowledged the omission. These failures were identified through observation, record review, and staff interviews.
Failure to Ensure Palatable and Nutritive Food Service
Penalty
Summary
The facility failed to ensure that food served to residents was palatable and maintained its nutritive value. During a resident council meeting, two residents, both alert and oriented, reported that their food tasted bland and lacked flavor. Review of their records showed that one resident was on a no added salt, controlled carbohydrate diet with regular texture and thin liquids, while the other was on a regular diet texture with thin liquids. Both residents expressed dissatisfaction with the taste of their meals. Test tray observations and tastings confirmed that both regular and pureed foods, including oven barbecue roast beef, vegetables, and mashed sweet potatoes, were bland. The cook who prepared the meals also verified the lack of flavor in both regular and pureed items. The registered dietitian acknowledged that foods served should be palatable and not bland, in accordance with facility policy. Additionally, observations revealed that both regular and pureed foods were held in heated ovens for extended periods, sometimes at temperatures ranging from 150 to over 400 degrees Fahrenheit, well before trayline preparation. The cook and registered dietitian both confirmed that foods should be prepared closer to trayline service to preserve taste and nutrients. Facility policy indicated that food should be held for as short a time as practical, with a maximum recommended holding time of one hour, but this was not followed.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage and preparation standards. Several cooking pans were found with brownish to blackish discolorations and rusty spots, which were acknowledged by the cook as needing replacement. Additionally, a bucket of corrosive chemical was stored beside food utensils such as paper plates, plastic knives, forks, and cups, contrary to facility policy. The ice scoop for the ice machine was placed in an area accessible to everyone, allowing for potential contamination, and this was confirmed by both the cook and the maintenance director. During tray line preparation, a dietary aide was seen pushing a meal tray cart outside the kitchen and then returning to continue food preparation without removing gloves, washing hands, or donning new gloves, as required by facility policy. These actions were acknowledged by the staff involved and confirmed by the director of staff development. The registered dietitian also verified all the findings. These deficiencies were observed in the context of food service provided to forty-nine residents, with no specific medical history or condition of the residents mentioned in the report.
Administrator Worked Without Current NHA License or Required Supervision
Penalty
Summary
The facility failed to ensure that the administrator (ADM) maintained a current and active Nursing Home Administrator (NHA) license while serving in the role without supervision. Review of the ADM's NHA license revealed that it had expired, and although the ADM wrote a check for the renewal application, he continued to work as the facility's administrator after the license expiration. During the period of observation, the ADM confirmed that his license was expired and there was no evidence of supervision by a licensed NHA during this time. Facility job descriptions and state Health and Safety Code requirements specify that an administrator must possess a current, unencumbered NHA license and may not act in the capacity of administrator after license expiration unless supervised by a licensed NHA for no more than 10 days, with at least 8 hours per week of direct onsite supervision. The ADM exceeded this 10-day period without the required supervision, in violation of state licensure requirements.
Failure to Offer and Assist with Advance Directives
Penalty
Summary
The facility failed to follow its policy and procedure regarding advance directives (AD) for six of eight sampled residents. For each of these residents, the clinical records and physician orders for life-sustaining treatment (POLST) forms indicated that no advance directive was documented. There was no evidence in the records that the facility discussed, offered, or assisted these residents in executing an advance directive upon admission or during their stay. Interviews with the Social Service Director (SSD) and Director of Nursing (DON) confirmed that the process of offering and assisting with advance directives was not completed for these residents. The facility's policy required that when an advance directive was not completed, the SSD or other designated staff should schedule a visit from the Ombudsman or patient advocate to assist the resident in completing the document. This step was not taken for the affected residents, as confirmed by both the SSD and DON during record reviews and interviews.
Infection Control Lapses in Hand Hygiene, PPE Use, and Equipment Maintenance
Penalty
Summary
Multiple infection control deficiencies were observed among staff and within the facility environment. One certified nursing assistant (CNA) failed to sanitize her hands before feeding a resident after touching various objects in the resident's room, despite facility policy and infection preventionist statements requiring hand hygiene before resident contact. Another CNA was observed handling soiled linens with gloved hands and then touching clean objects, such as a door knob, curtain, and a resident's glass, and walking into the hallway without removing contaminated gloves or performing hand hygiene, contrary to facility policy and infection control standards. Additional deficiencies included improper management of oxygen equipment and personal protective equipment (PPE). A resident with chronic obstructive pulmonary disease (COPD) was observed using undated oxygen tubing, and another resident's oxygen concentrator filter was found to be dusty, both in violation of facility policies requiring regular dating and cleaning of such equipment. A CNA was also seen wearing a surgical face mask below the nose while in the hallway, which was confirmed as improper by both the CNA and the infection preventionist. Further observations revealed that residents' personal care items, such as wash basins and emesis basins, were not labeled with resident names, creating a risk of cross-use in shared bathrooms. In a room requiring enhanced barrier precautions (EBP), there was no closed lid receptacle for discarding used PPE, despite signage indicating the need for gowns and gloves. Staff interviews and policy reviews confirmed that these practices did not align with facility infection control protocols.
Failure to Clean Dryer Lint Filters as Required
Penalty
Summary
During an observation of the laundry room, two dryers were found operating with their lint filters covered by a thick layer of white lint. The housekeeping/laundry staff member confirmed that the lint filters had not been checked or cleaned before starting the dryers that morning, stating that they had forgotten to perform this task. The housekeeping/laundry supervisor also confirmed that staff are expected to check and clean lint filters before using the dryers, as outlined in the facility's policy and procedure, which requires lint filters to be cleaned after each use or at least daily. The failure to clean the lint filters as required was directly observed and acknowledged by both staff and supervisor.
Failure to Develop and Implement Comprehensive Care Plans for Oxygen Therapy and Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents with significant clinical needs. For one resident, who was admitted with chronic kidney disease and had a physician's order for continuous oxygen inhalation at 2 liters per minute via nasal cannula to maintain oxygen saturation above 95%, there was no care plan addressing the use of continuous oxygen. This omission was confirmed through observation, record review, and staff interviews, including with the infection preventionist and the director of nursing, both of whom acknowledged the absence of a care plan for oxygen therapy. For another resident with diagnoses including type 1 diabetes, Alzheimer's disease, and depression, there was a documented significant weight loss of 16.6 pounds (10.5%) over six months. Despite this, there was no care plan in place to address the resident's significant weight loss, as confirmed by review of dietary and weight management notes, as well as staff interviews. The lack of care planning for these clinical issues meant that the residents did not have documented, measurable objectives and interventions to address their needs, as required by facility policy.
Pain Medication Administered Outside Physician Orders
Penalty
Summary
Licensed nurses administered hydrocodone-acetaminophen 5-325 mg to Resident 99 for pain levels of 7 and 5, despite physician orders specifying that this medication was to be given only for severe pain rated 8-10. Resident 99, who was admitted with polyneuropathy, had physician orders in place requiring pain level monitoring every shift and administration of hydrocodone-acetaminophen only for severe pain. Review of the Medication Administration Record confirmed that the medication was given for moderate pain levels, contrary to the physician's orders. The Director of Nursing confirmed that the nurses did not follow the prescribed protocol and should have notified the physician for pain levels less than 8, as per the facility's policy on pain assessment and management.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to ensure that two residents with chronic obstructive pulmonary disease (COPD) received oxygen therapy as ordered by their physicians. For one resident, the physician's order specified oxygen at 2 liters per minute (LPM) every shift, but during observation, the resident was found receiving only 1.5 LPM. The licensed vocational nurse (LVN) confirmed that the resident should have been on 2 LPM as per the physician's order. Similarly, another resident with a COPD diagnosis had a physician's order for oxygen at 2 LPM every shift for symptoms of shortness of breath and chest pain, but was observed receiving only 1.2 LPM of oxygen. The LVN also confirmed this did not match the physician's order. Review of the facility's policy on oxygen treatment indicated that oxygen therapy should be administered as ordered by the physician, including adjusting the oxygen flow as specified. The observations and interviews demonstrated that the facility did not follow physician orders for oxygen administration for these two residents, resulting in a failure to provide safe and appropriate respiratory care as required.
Failure to Separate Administration of Iron and Calcium Supplements
Penalty
Summary
The facility failed to ensure the effective use of medications for a resident diagnosed with anemia by administering ferrous sulfate (iron supplement) and calcium at the same time each day. The resident had physician orders for both medications to be given at 9 a.m., and this practice began when the calcium order was started. Clinical record review confirmed that both medications were administered concurrently since the initiation of the calcium order. During an interview, the pharmacy consultant confirmed that ferrous sulfate and calcium should be administered at least two hours apart due to a significant drug-drug interaction that decreases iron absorption. Reference to Lexicomp, a nationally recognized drug information resource, indicated that co-administration of these medications can decrease iron absorption by an average of 60%. The facility's policy required the pharmacy to screen for drug interactions with each new medication order, but this was not effectively implemented in this case.
Failure to Identify and Act on Medication Irregularities During Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified and reported medication irregularities during the monthly medication regimen review (MRR) for one resident, and failed to follow up on MRR recommendations for another resident. For one resident with a history of a left femur neck fracture, a physician order was written for cholecalciferol (vitamin D3) at a dose of 2000 mcg daily, which is significantly higher than the manufacturer’s recommended adult dose of 25 mcg/1000 IU daily. This high-dose order was not identified or addressed in the MRRs, and the resident received the excessive dose for over ten months. Both the registered nurse and the director of nursing confirmed that the order should have been for 2000 IU, not 2000 mcg, and acknowledged that the consultant pharmacist did not report or recommend correction of this irregularity during the monthly reviews. Additionally, for another resident who had a long-term order for omeprazole 20 mg daily, the consultant pharmacist documented a recommendation for the physician to evaluate the continued need for the medication due to potential risks associated with prolonged use. However, this recommendation was not presented to the physician, and there was no evidence of physician review or response. The facility’s policy requires that resident-specific MRR recommendations be documented and acted upon, but this process was not followed in this case. These failures resulted in one resident receiving a medication at more than the therapeutic dose for an extended period, and another resident continuing a medication without appropriate physician review of the pharmacist’s recommendation. The facility’s own policies and procedures require thorough MRRs and timely follow-up on pharmacist recommendations, but these were not adhered to in the cases reviewed.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident immediately, as required by state law. The incident involved a resident with dementia, weakness, and major depressive disorder, who was allegedly abused by a Certified Nurse Aide (CNA). The abuse was reported by another CNA, who witnessed the alleged abuser shoving graham crackers into the resident's mouth and pulling the resident's ear. The reporting CNA delayed reporting the incident due to feeling intimidated by the alleged abuser. The Director of Staff Development (DSD) confirmed that the abuse was not reported immediately, as required by the facility's policy, which mandates reporting within two hours. The Director of Nursing (DON) was informed of the incident two days later and reported it to the ombudsman and the California Department of Public Health. The facility's policy on abuse, neglect, mistreatment, and misappropriation of resident property requires immediate reporting of abuse allegations, but this protocol was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Jose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| White Blossom Care Center | 0.6 mi | ★★★★★ | 22 | 0 |
| The Redwoods Post-acute | 1.1 mi | ★★★★★ | 1 | 0 |
| A Grace Sub Acute & Skilled Care | 1.1 mi | ★★★★★ | 3 | 0 |
| Creekside Post-acute | 1.6 mi | ★★★★★ | 2 | 0 |
| Skyline Healthcare Center - San Jose | 1.9 mi | ★★★★★ | 1 | 0 |
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