Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 O'connor Hospital D/p Snf during CMS and state inspections, most recent first.
A resident had a rectal tube in place without a provider order, and two residents with GTs received meds without the required water flush before administration. Another resident was given crushed medication without staff using two identifiers to verify identity. The findings involved RN and LVN observations, record review, and facility policy that required a provider order for the stool management system, flushing enteral tubes before meds, and verifying residents with at least two identifiers.
Medication administration errors exceeded the allowed rate when staff failed to flush two residents’ G-tubes before giving meds and failed to use two resident identifiers before giving a crushed med to another resident. One LVN administered crushed meds through a G-tube without the ordered water flush, another LVN did the same with a second resident, and a third med pass was given without checking ID as required by policy.
The facility failed to properly assess and document the use of side rails for 23 residents, as required by their policy. Observations showed that side rails were used without offering alternatives or obtaining informed consent. Staff confirmed that no alternatives were provided, and assessments did not justify the use of side rails, posing a risk of entrapment and injury.
The facility failed to post 'Oxygen In Use' signs for 19 residents receiving oxygen therapy, as required by their policy. Observations revealed the absence of these signs, and a nurse confirmed the facility's usual practice of not posting them. Additionally, a portable oxygen tank was found in a resident's room who was documented as being on room air, indicating a possible communication lapse.
A resident was found without the call light within reach, as it was attached to a monitor above the bed. The resident, who was alert and oriented, stated that staff sometimes forget to provide the call light after care. RN J confirmed that CNA K had forgotten to place the call light within reach. The facility's policy requires the call bell to be kept within reach, which was not followed.
A facility failed to apply a right hand splint for a resident with contractures, as ordered by the physician. Instead, rolled hand towels were used, and staff relied on family members to apply the splint. Interviews revealed that CNAs were expected to apply the splint, but it was not being done, contrary to the facility's policy for maintaining residents' highest level of functioning.
The facility failed to accurately account for controlled medications for a resident, as medications were signed out of the Controlled Drug Record but not documented on the Medication Administration Record. Nursing staff admitted to administering the medications but forgetting to sign the MAR, leading to a deficiency in pharmaceutical services.
The facility failed to monitor side effects of anticoagulant medications for two residents, risking complications. One resident with anoxic brain injury was on Rivaroxaban, and another with atrial fibrillation was on Apixaban. Required monitoring for bleeding and thrombocytopenia was not documented or performed, as confirmed by staff interviews and record reviews.
A facility was found to have an 8% medication error rate due to two incidents. One involved an LVN not waiting the required time between administering eye drops, and another involved a failure to flush a G-tube before medication administration, both against facility policy.
Two LVNs failed to follow infection control protocols during medication administration for residents with G-tubes. One LVN did not change gloves or sanitize hands after handling a fan, and another did not do so after moving a bedside table. Both acknowledged the need for proper hand hygiene, which was not adhered to, as per facility policy.
A facility failed to administer the pneumococcal conjugate vaccine 20 (PCV20) to a resident who had a history of receiving the PCV13 and PPSV23 vaccines. The resident's immunization consent form authorized the vaccine, but the facility did not follow its policy for vaccine screening and administration. The CDC recommends PCV20 for adults who have received PCV13 and PPSV23, at least five years after the last pneumococcal vaccine.
The facility failed to maintain an effective pest control program, leading to the presence of flies and spiders in the activity room. Flies were observed on multiple occasions, and an LVN caught a spider on a tablet keyboard. The DD confirmed the issue and contacted pest control, while the CM acknowledged the risk of infection due to pests.
Unordered rectal tube and medication administration errors
Penalty
Summary
Resident 3 had a rectal tube in place for loose stool, but there was no physician order for the rectal tube. During observation, a covered collection bag connected to tubing was seen hanging on the side of the resident’s bed, and RN A and LVN B both verified that the rectal tube remained in place and that no physician order existed. The resident’s care plan for bowel elimination indicated the rectal tube was in place on admission and had been changed on 8/5/25, and the facility policy required a provider order for stool management system placement and maintenance. Resident 5, who had diagnoses including MVA with severe injury, right hemicraniectomy, cranioplasty, chronic respiratory failure, and gastrostomy status, was observed receiving medications through the GT without a water flush before administration. LVN C crushed three medications individually, diluted them with water, brought them to the bedside, checked GT placement and residual, and then administered the medications without flushing the tube first. The resident’s nursing orders directed staff to flush the tube with 50 ml of water before giving medications, and LVN C stated she usually gives a little water before medication but did not do so this time. Resident 12, who had chronic respiratory failure and a comatose state following brain injury, also received medications through the G-tube without a water flush before administration. LVN B turned off the feeding pump, disconnected the tubing, checked placement and residual, and began medication administration without flushing the tube. Resident 16, who had traumatic brain injury, dementia, hypertension, and dysphagia, was given crushed medication mixed with pudding without staff first checking the resident’s identification. LVN C stated she should have checked the ID but knew the resident well, and RN A stated that two identifiers, such as the resident’s face compared with the photo in the eMAR and the armband, are used before medication administration. The facility’s medication administration policy required use of at least two resident identifiers.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility had a medication error rate of 8.1% after three medication errors were identified during 37 medication administration opportunities for three residents. During observation, an LVN prepared three crushed medications for one resident with a gastrostomy tube and administered them through the tube without flushing the tube with water first, even though the resident’s orders directed staff to flush the tube with 50 mL of water before giving medications. The LVN stated she usually gives a little water before medication but did not do so during this administration. A second LVN also administered medications through another resident’s G-tube without flushing the tube with water before medication administration, despite stating she usually flushes with 30 mL of water before giving medications. A third medication administration error occurred when an LVN gave a crushed medication mixed with pudding to a resident without first checking the resident’s identification. The LVN stated she should have checked the ID before giving the medication but knew the resident well. The RN stated that two resident identifiers, such as comparing the resident’s face to the photo in the eMAR and checking the armband, are used before administering medications. Facility policy required enteral tubes to be flushed with at least 15 mL of water before medications and required residents to be identified using at least two identifiers before medication administration.
Improper Use of Side Rails for 23 Residents
Penalty
Summary
The facility failed to ensure the proper use of side rails for 23 residents, as observed during a survey. For two residents, the Siderail Assessment indicated that side rails were not required, yet they were observed with side rails in the upright position. This discrepancy was confirmed by a Licensed Vocational Nurse and the Clinical Manager, who acknowledged that the use of side rails was not indicated and could pose a risk of entrapment and serious injury. Additionally, the facility did not offer or attempt alternatives to side rails for any of the 23 residents before their use. Observations revealed that all these residents had side rails installed, and interviews with staff confirmed that no alternatives were provided or documented. The Director of Operations admitted that alternatives were not offered prior to the installation of side rails. The facility's policy and procedure on side rails require that residents be assessed for the use of side rails and that informed consent be obtained. However, the facility did not adhere to this policy, as evidenced by the lack of documentation and assessment for the use of side rails for the residents involved.
Failure to Post 'Oxygen In Use' Signs for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide proper care and treatment services for the use of oxygen for 19 residents who were receiving oxygen therapy. During observations, it was noted that there were no 'Oxygen In Use' signs posted at the doors or side walls of the rooms of these residents. This deficiency was confirmed by a Licensed Vocational Nurse (LVN) who stated that the facility does not usually put oxygen signs on the doors, despite the facility's policy requiring such signage. Additionally, a portable oxygen tank was observed at the head of the bed in a resident's room who was indicated as being on room air, suggesting a lack of proper documentation or communication regarding the resident's oxygen needs. The facility's policy on oxygen therapy, which mandates the placement of 'Oxygen In Use' signs, was not adhered to, potentially compromising the safety of residents receiving oxygen therapy.
Call Light Not Within Reach for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for one of the sampled residents, Resident 22. During an observation and interview, it was noted that Resident 22, who was awake and sitting up in bed, did not have the call light within reach. The call light was attached to a monitor above the bed, and Resident 22, who was alert and oriented, mentioned that staff sometimes forget to provide the call light after changing her. Resident 22 expressed that she waits for staff to return and remember to give it to her. Further observation and interview with RN J revealed that the call light was indeed out of reach because CNA K, who had been providing care, forgot to place it within Resident 22's reach before leaving the room. The facility's policy, dated 8/24/22, states that the call bell should be kept within reach of the patient, which was not adhered to in this instance.
Failure to Apply Hand Splint for Contracture Management
Penalty
Summary
The facility failed to apply a right hand splint for a resident, identified as Resident 7, who was experiencing contractures in both hands. The physician had ordered the application of a right soft hand splint as tolerated, with the option for family members to apply it as well. However, during an observation, it was noted that the splint was not applied, and instead, rolled hand towels were placed in the resident's palms. A Certified Nursing Assistant (CNA) stated that she always used hand towels to prevent contractures and relied on the family to apply the splint. Further interviews and record reviews revealed that the facility's staff, including Registered Nurses (RNs), were aware that the splint should be applied by the CNAs in the morning, and not solely by family members. The facility's policy emphasized early detection and intervention to maintain residents at their highest level of functioning, yet the splint was not being applied as ordered, potentially worsening the resident's contractures.
Controlled Medication Accountability Deficiency
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for one of the residents, leading to a deficiency in pharmaceutical services. During a survey, it was found that the Controlled Drug Record (CDR) for a resident receiving PRN controlled medications did not reconcile with the Medication Administration Record (MAR). Specifically, Tramadol and Butalbital-Acetaminophen-Caffeine were signed out of the CDR but not documented on the MAR as administered to the resident. This discrepancy was acknowledged by the nursing staff involved, who admitted to forgetting to sign the MAR after administering the medications. The deficiency was identified through interviews and record reviews with the nursing staff and the Clinical Manager. The staff members involved, including a Registered Nurse and a Licensed Vocational Nurse, confirmed that they had administered the medications but failed to document the administration in the MAR. The facility's policy on medication administration, which requires medications to be charted immediately after being administered, was not followed, resulting in inaccurate accountability of controlled substances.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to adequately monitor the side effects of anticoagulant medications for two residents, which could potentially lead to complications and adverse effects. Resident 7, who was admitted with an anoxic brain injury, had a physician's order for Rivaroxaban to treat deep vein thrombosis and pulmonary embolism. The physician's orders required monitoring for signs of bleeding and thrombocytopenia every shift. However, a review of the Medication Administration Record (MAR) for May 2024 revealed no documentation by the nursing staff confirming that this monitoring was performed every shift. During an interview, Registered Nurse C confirmed the lack of evidence in the MAR for the required monitoring. Similarly, Resident 1, diagnosed with atrial fibrillation, was prescribed Apixaban. The Consultant Pharmacist's Medication Regimen Review recommended monitoring for signs of bleeding and thromboembolism. However, during interviews and record reviews, both Registered Nurse C and the Clinical Manager acknowledged that the monitoring of side effects was not documented in the MAR and was not being performed. The facility's policy required that medication regimen review recommendations be documented and acted upon within 30 days, but this was not followed in these cases.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 8% during a survey, exceeding the acceptable threshold of 5%. This was identified through two specific incidents involving medication administration errors. In the first incident, a Licensed Vocational Nurse (LVN) administered Genteal Tears, an ophthalmic solution, to a resident without waiting the recommended 3 to 5 minutes between drops for optimal absorption, as per the facility's policy. The LVN admitted to not waiting the required time between administering the drops. In the second incident, another LVN failed to flush a gastrostomy tube (G-tube) with water before administering medications to a resident, contrary to the facility's policy which requires flushing with 50 cc of water to ensure tube patency. This was confirmed by interviews with multiple nursing staff, including a Registered Nurse and the Clinical Manager, who all stated that the G-tube should be flushed before medication administration. These errors indicate a deviation from the facility's established medication administration procedures.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to implement proper infection control and prevention practices during medication administration for two residents. Licensed Vocational Nurse (LVN) E did not change gloves or perform hand hygiene after handling an electrical fan on a bedside table before administering medications through a gastrostomy tube (G-tube) for Resident 11. This oversight occurred despite the nurse acknowledging the need to change gloves and sanitize hands after touching the fan and before proceeding with medication administration. Similarly, LVN F did not change gloves or sanitize hands after moving a bedside table before administering medications through a G-tube for Resident 9. The nurse admitted to the lapse in protocol, recognizing the necessity of changing gloves and performing hand hygiene before administering medications. The facility's policy on infection control and hand hygiene, which requires hand sanitization after contact with inanimate objects in the patient's vicinity, was not followed in these instances.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident was offered and/or received the pneumococcal conjugate vaccine 20 (PCV20), which is recommended for adults who have previously received the PCV13 and PPSV23 vaccines. During an interview and record review, the Minimum Data Set Coordinator (MDS) confirmed that the resident was admitted with a history of receiving the pneumococcal polysaccharide vaccine (PPSV23) in 2011 and the pneumococcal pneumonia vaccine (PCV13) in 2014. Despite this history, the MDS did not administer the PCV20 vaccine to the resident upon reviewing the immunization record. The resident's Immunization Consent Authorization Form, signed by the responsible party, authorized the facility to administer the pneumococcal vaccine. However, the facility's policy and procedure for adult pneumococcal vaccine screening and administration, which includes using vaccine history and an algorithm to determine eligibility for PCV20 or PPSV23, was not followed. According to the CDC's recommendations, adults who have received PCV13 and PPSV23 should receive a dose of PCV20 at least five years after the last pneumococcal vaccine. This oversight increased the potential for inadequate immunity to pneumococcal infections for the resident.
Pest Control Deficiency in Activity Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and spiders in the activity room. On multiple occasions, flies were observed in the activity room, specifically on 5/14/24 and 5/17/24. Additionally, on 5/16/24, a Licensed Vocational Nurse (LVN B) caught a spider crawling on a tablet keyboard in the same room. These observations were confirmed by the Deputy Director (DD) during a concurrent observation and interview on 5/17/24, who acknowledged the presence of a fly and contacted the pest control service. The Clinical Manager (CM) also confirmed that flies and spiders should not be present in the activity room due to the risk of spreading germs and potentially causing infections among residents and family members.
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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) |
|---|---|---|---|---|
| Skyline Healthcare Center - San Jose | 0 mi | ★★★★★ | 1 | 0 |
| The Win Post-acute | 0.7 mi | ★★★★★ | 1 | 0 |
| White Blossom Care Center | 1.3 mi | ★★★★★ | 22 | 0 |
| Courtyard Care Center | 1.7 mi | ★★★★★ | 2 | 0 |
| A Grace Sub Acute & Skilled Care | 1.8 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.