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 Plum Tree Care Center during CMS and state inspections, most recent first.
A resident's family requested medical records, but the facility did not provide the records within the two business days required by its own policy. The records were sent several days after the request, resulting in a delay for the family.
A resident with multiple diagnoses did not receive several prescribed medications as ordered, and staff failed to document the reasons for withholding these medications or notify the PCP, as required by facility policy. Interviews with nursing staff and the DON confirmed the lack of documentation and notification, and the resident reported not receiving medications for several days.
A resident with diabetes and congestive heart failure had abnormal CBC and CMP lab results on two occasions, but the PCP and responsible party were not notified by nursing staff as required by facility policy. The DON confirmed the lack of notification and documentation.
Staff did not assess or report abnormal findings in a resident's urinary catheter, despite care plan and physician order requirements, and failed to properly document receipt of controlled medications for two residents. These deficiencies included missing nurse signatures, dates, and medication amounts on controlled drug records, as confirmed by interviews and policy review.
The facility did not post required 'oxygen in use' or 'no smoking' signage on the doors of rooms where three residents had oxygen concentrators present or in use, despite physician orders for oxygen therapy. Staff and policy confirmed that signage should have been posted for safety, but it was not present during observations.
Surveyors found that staff failed to label an opened multi-dose eye drop medication for a resident with the date it was opened, and did not remove expired OTC laxative packets and expired suction machine tubing from the medication room. The DON and LVN confirmed these deficiencies, which were contrary to facility policy requiring proper labeling and timely removal of expired items.
Staff did not follow infection control protocols in multiple instances, including leaving a feeding tube uncovered and disconnected, allowing a nephrostomy collection bag to rest on the floor, and failing to properly store a nebulizer mask after use. These actions involved residents with gastrostomy tubes, nephrostomy tubes, and COPD, and were confirmed by nursing and infection prevention staff as not meeting facility policy or manufacturer recommendations.
A resident with a nephrostomy collection bag was observed with the bag uncovered and visible on the floor, contrary to facility policy requiring privacy covers for such devices. Staff confirmed the bag should have been covered to maintain the resident's dignity.
A resident with hemiplegia, hemiparesis, and moderate cognitive impairment was found restrained to a wheelchair with a gait belt, without a physician's order or documented medical need. Staff interviews confirmed that restraints were not permitted except under specific conditions, and facility policy required assessment and consent before use. The restraint was discovered by a CNA, who removed it after realizing the resident could not get up, and the DON confirmed the restraint was not appropriate for the situation.
A resident with new diagnoses of anxiety disorder and delusional disorder, along with the initiation of antipsychotic medication, did not have a timely PASRR assessment completed or submitted to the state agency as required by facility policy. The PASRR was only completed after a surveyor began an investigation and requested the documentation.
Surveyors observed an opened bag of hamburger buns in the kitchen pantry that was past its use-by date and lacked proper labeling. The Dietary Director confirmed the buns should have been discarded and that facility policy requires supervisors to ensure food items are not past expiration dates.
A resident at moderate fall risk fell during a therapy session due to inadequate assistance. The resident, with impaired balance and a history of falls, was not properly supported by a gait belt while attempting to pick up an object from the floor. The Rehab Aide assisting the resident was unsure of the required assistance level, and the Physical Therapy Assistant was monitoring remotely, leading to the resident's fall and injury.
The facility failed to document a resident's oxygen saturation levels as prescribed and did not notify the physician or obtain an order for transfer to an acute care hospital during a change in condition. The DON confirmed these lapses in documentation and procedure adherence.
The facility failed to implement proper infection control practices when a resident's oxygen tubing and humidifier were not replaced and labeled according to policy. Both the RN and DON confirmed that the tubing and humidifier should be changed and labeled weekly, which was not done.
Failure to Timely Release Medical Records per Facility Policy
Penalty
Summary
The facility failed to follow its own policy regarding the timely release of medical records for one resident. The policy required that medical records be provided within two business days (excluding weekends and holidays) after receiving a request. In this case, the medical records department received a signed request for a resident's medical records via email on 4/30/25, but the records were not sent to the requestor until 5/9/25. Interviews with the medical records staff and the administrator confirmed that the request was received and that the records were sent outside the required timeframe. Review of the facility's policy and email correspondence further substantiated that the records were not provided within the mandated two-day period, resulting in the resident's family receiving the records late.
Failure to Document and Notify PCP When Withholding Medications
Penalty
Summary
The facility failed to document the reasons for withholding medications and did not notify the primary care physician (PCP) when medications were withheld for one resident. The resident, who was admitted with diagnoses including tachycardia, depression, anxiety, and headache, had intact cognition and was responsible for daily decision-making. Medication administration records showed that several doses of prescribed medications, including auvelity, ivabradine, and emgality, were not administered as ordered. The electronic medical record indicated that these medications were held, but there was no documentation explaining the reasons for withholding them or evidence that the PCP was notified. Interviews with the resident, a licensed vocational nurse (LVN), and the director of nursing (DON) confirmed that the medications were withheld and that the required documentation and notifications were not completed. The LVN stated that medications were likely held due to lack of supply, and both the LVN and DON acknowledged that facility policy requires documentation of the reason and PCP notification when medications are withheld. Review of facility policy further confirmed these requirements, but no such documentation or notifications were found in the resident's records.
Failure to Notify PCP and Responsible Party of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the primary care physician (PCP) and the resident's responsible party (RP) of abnormal blood test results for a resident with diagnoses of diabetes type 2 and congestive heart failure. The resident had orders for complete blood count (CBC) and comprehensive metabolic panel (CMP) tests, which were performed on two separate dates. The results from both dates showed several out-of-range values, including high glucose, blood urea nitrogen (BUN), BUN/creatinine ratio, carbon dioxide, RDW, absolute monocytes, absolute basophils, and low hemoglobin. A review of the resident's nursing notes revealed no documented evidence that the PCP or RP were informed of these abnormal results. During an interview, the Director of Nursing (DON) confirmed that licensed nursing staff did not notify the PCP or RP of the abnormal blood work. The facility's policy requires staff to notify the physician and document the communication, but this was not followed in this instance.
Failure to Follow Professional Standards in Catheter Care and Controlled Drug Documentation
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed for three out of six sampled residents. For one resident with a suprapubic urinary catheter and a history of urinary tract infections, urogenital implants, and neuromuscular bladder dysfunction, staff did not assess or report the presence of white color particles and cloudy urine in the catheter drain tube to the medical doctor. Although the care plan and physician orders required monitoring and reporting of such symptoms, there was no documentation of assessment or notification to the physician. Both a certified nursing assistant and a licensed vocational nurse confirmed the abnormal findings during interviews and acknowledged that they had not previously noticed or reported the issue. Additionally, the facility did not maintain proper controlled drug records for two residents who were prescribed morphine sulfate and oxycodone for pain management. Upon review, the controlled drug records for both residents were missing the licensed nurse's signature, date, and documentation of the amount of medication received from the pharmacy. Interviews with registered nurses and the director of nursing confirmed these omissions and stated that the records should have been properly completed as per facility policy. Facility policies required observation and reporting of unusual findings related to urinary catheters and completion of controlled medication accountability records upon receipt of Schedule II medications. The lack of assessment, documentation, and reporting for the resident with the urinary catheter, as well as the incomplete controlled drug records for the two residents, constituted failures to meet professional standards of quality care and medication accountability.
Failure to Post Required Oxygen Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to provide proper oxygen care and treatment services for three residents by not posting required oxygen signage on the doors of rooms where oxygen concentrators were present or in use. For one resident, a room air concentrator was placed next to the bed with no 'oxygen in use' or 'no smoking' sign posted, despite physician orders for oxygen therapy to address hypoxia and shortness of breath. Nursing staff and the DON confirmed that signage should have been posted when oxygen was in use. Two additional residents had oxygen concentrators at the bedside, with physician orders for oxygen therapy, but there was no oxygen-related signage posted on their doors. Observations and interviews with the Infection Preventionist and DON confirmed the absence of required signage and acknowledged that it should have been present for safety. Review of facility policies indicated that 'No Smoking/Oxygen in Use' signs are required to be posted when oxygen is administered, and that the maintenance department is responsible for ensuring signage is in good repair and regulatory compliance.
Failure to Properly Label and Remove Expired Medications and Supplies
Penalty
Summary
Surveyors observed multiple failures in medication and supply management within the facility. An opened multi-dose eye drop medication prescribed for a resident was found on the medication cart without an opened date labeled on the bottle or its storage packet. The licensed vocational nurse confirmed that the medication was in use and that staff had not documented the date it was opened, making it impossible to determine when the medication should be discontinued according to manufacturer guidelines. The facility's policy requires staff to label multi-dose medications with the date opened, but this was not followed in this instance. Additionally, expired over-the-counter laxative packets were found stored in the medication room supply cabinet, and expired suction machine tubing was present in the supply storage area. The director of nursing confirmed that these items were expired and should have been removed during routine supply checks. The facility's policy states that staff are responsible for verifying and removing expired medications and supplies, but this process was not carried out as required.
Failure to Implement Proper Infection Control Practices
Penalty
Summary
Staff failed to implement proper infection control practices in several instances involving residents with specialized medical needs. In one case, a resident with a gastrostomy tube (GT) had the end of their feeding tube left uncovered and disconnected from the GT while not in use. The feeding tube remained attached to a partially full feeding formula bottle, and both were intended to be reused for the next feeding. The nurse confirmed the tube should have been covered when not in use, and the infection preventionist verified that the tube was left uncovered, which was not in accordance with manufacturer recommendations. Another incident involved a resident with a nephrostomy tube, where the collection bag was observed lying on the floor while the resident was in bed. The infection preventionist and the director of staff development both confirmed that the collection bag was not properly positioned, as it should have been hanging to drain correctly and to prevent infection. Facility policy requires maintaining a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections. Additionally, a resident with chronic obstructive pulmonary disease (COPD) was found with a nebulizer mask hanging by its string on the machine, still attached to the medication cup and tubing, after use. The director of nursing acknowledged that the nebulizer mask should have been placed in a plastic bag, and the infection preventionist stated that masks must be rinsed after use and stored in a plastic bag. Facility policy specifies that nebulizer equipment should be rinsed, disinfected, and stored in a labeled plastic bag once completely dry.
Failure to Provide Privacy for Nephrostomy Collection Bag
Penalty
Summary
Staff failed to maintain the dignity and privacy of a resident with a nephrostomy collection bag. During an observation, the resident was found lying in bed with the nephrostomy collection bag placed on the floor, uncovered, and with its contents visible. Both the Infection Preventionist and the Director of Staff Development confirmed that the nephrostomy collection bag should have been covered with a privacy bag, in accordance with facility policy. The resident had a medical history including malignant neoplasm of the cervix, unspecified cystitis, and a urinary tract infection. The facility's policy on dignity, revised in February 2021, requires that residents be cared for in a manner that promotes their well-being and prohibits practices that compromise dignity, specifically stating that urinary catheter bags should be covered. The failure to provide a privacy bag for the nephrostomy collection bag was directly observed and acknowledged by facility staff.
Resident Restrained to Wheelchair Without Medical Order or Justification
Penalty
Summary
A deficiency occurred when a resident with diagnoses including hemiplegia, hemiparesis, and a mood disorder was found restrained to a wheelchair using a gait belt, without a medical order or documented need for restraint to treat a medical symptom. The resident, who only spoke Chinese and had moderate cognitive impairment, was unable to remove the restraint and was observed pointing to his abdomen, indicating possible distress. Staff interviews revealed that the use of restraints was not permitted in the facility, and there was no policy allowing restraint for convenience or without proper assessment and physician order. The incident was discovered when a CNA found the resident in his room, unable to get up from the wheelchair, with the restraint hidden under a jacket. The CNA removed the restraint after realizing the resident could not move. Another CNA admitted to placing the gait belt around the resident and the wheelchair because the resident "goes around," but did not remove it afterward. The DON confirmed that gait belts are intended for transfers and ambulation, not for restraining residents, and demonstrated that a confused resident would not be able to unlock the type of buckle used. A review of facility policies confirmed that restraints are only to be used for the safety and well-being of residents after alternatives have been tried, and only with a physician's written order and consent. The policy also specifies that restraints must be easily removable and not used for staff convenience or discipline. The facility's resident rights documentation further states that residents are to be free from physical restraints not required to treat medical symptoms, and must be treated with dignity and respect at all times.
Failure to Complete Timely PASRR Assessment After Significant Change in Mental Condition
Penalty
Summary
The facility failed to follow its policy and procedure for the Pre-Admission Screening and Resident Review (PASRR) process for a resident who experienced a significant change in mental condition. The resident was initially admitted and later readmitted with no serious mental illness or prescribed psychotropic medications documented on the original PASRR. However, subsequent clinical documentation showed new diagnoses of anxiety disorder and delusional disorder, as well as the initiation of antipsychotic medication. Despite these significant changes, there was no documented PASRR assessment completed or submitted to the state agency until after a health facility evaluator nurse began an investigation and requested the documentation. Interviews with the Director of Nursing confirmed that the facility did not complete or submit a new PASRR assessment following the resident's new mental health diagnoses and the start of antipsychotic medication, as required by facility policy. The facility's policy states that a new PASRR should be completed and submitted to the state agency when there is a significant change in a resident's mental condition. The deficiency was identified when the PASRR was only completed after the surveyor's intervention, rather than at the time of the resident's significant change.
Expired Food Item Found in Kitchen Pantry
Penalty
Summary
During an observation and interview in the facility's kitchen pantry, surveyors found an opened bag of hamburger buns containing six buns that were past their labeled use-by date. The Dietary Director confirmed that bread could be stored for seven days from the labeled date and acknowledged that the hamburger buns dated 3/6/25 should have been discarded. Additionally, there was no sticker indicating a use-by date for the hamburger buns, unlike another loaf of bread that was properly labeled. Review of facility policies indicated that food items are to be stored in compliance with safe food handling practices and that supervisors are responsible for ensuring food items are not past their use-by or expiration dates. The failure to discard the expired hamburger buns and lack of proper labeling did not comply with these policies.
Failure to Prevent Resident Fall During Therapy
Penalty
Summary
The facility failed to provide adequate assistance to prevent an accident involving a resident, who was at a moderate risk of falling due to generalized weakness and impaired balance. The resident's care plan indicated the use of a gait belt and physical therapy devices to mitigate fall risks. However, during a physical therapy session, the resident attempted to pick up an object from the floor while seated in a wheelchair, an activity that had not been attempted previously due to medical conditions or safety concerns. During the therapy session, the resident was being assisted by a Rehab Aide (RAA) while a Physical Therapy Assistant (PTA) monitored the session remotely. The Director of Rehab (DOR) was present, holding a camera for the PTA. The RAA did not hold onto the resident's gait belt, and the resident fell forward out of the wheelchair, resulting in a forehead laceration. The RAA was unsure of the level of assistance required and was not fast enough to prevent the fall. Interviews with the staff revealed that the PTA was not aware of the exact assistance needed for the resident, and the DOR acknowledged that the resident's ability to pick up objects was not evaluated due to safety concerns. The facility's policy on falls and fall risk management emphasized identifying interventions to prevent falls, but these were not effectively implemented during the incident.
Failure to Document Oxygen Saturation and Notify Physician
Penalty
Summary
The facility failed to provide services according to professional standards of practice for one resident. Specifically, the staff did not document Resident 1's oxygen saturation levels as prescribed by the physician, which required the oxygen saturation to be greater than 90%. During a review, it was found that the Treatment Administration Record (TAR) for Resident 1 did not indicate that the oxygen saturation was checked for the evening shift. The Director of Nursing (DON) confirmed that the nurse should have charted the oxygen check but did not do so. Additionally, the facility failed to notify the physician regarding Resident 1's change of condition and did not obtain a physician order for the transfer to an acute care hospital. The Progress Notes and Change in Condition Evaluation for Resident 1 indicated swelling on the lateral border of the left forearm, but there was no documentation of physician notification. The DON confirmed that the evaluation was incomplete and that there was no physician order for the transfer. The facility's policies and procedures for documentation, oxygen administration, and change in condition were not followed in this case.
Failure to Implement Proper Infection Control Practices
Penalty
Summary
The facility failed to implement proper infection control practices for one resident when the resident's oxygen tubing and humidifier were not replaced and labeled according to facility policy. During an observation and interview, it was noted that the oxygen tubing and humidifier in the resident's room did not have dates indicating when they were last replaced. The Registered Nurse confirmed the absence of dates and acknowledged that the tubing and humidifier should be changed and labeled every week. The Director of Nursing also confirmed that the nurses should have changed the tubing and humidifier weekly and labeled them with the date and their initials. The facility's policy indicated that oxygen tubing and humidifiers should be changed and labeled every seven days and as needed.
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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) |
|---|---|---|---|---|
| Woodlands Healthcare Center | 0.1 mi | ★★★★★ | 2 | 0 |
| Childrens Hc Org No Ca -pediatric Hospital D/p Snf | 0.5 mi | ★★★★★ | 0 | 0 |
| Stonebrook Health And Rehabilitation | 0.5 mi | ★★★★★ | 2 | 0 |
| Almaden Health And Rehabilitation Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Camden Postacute Care, Inc | 1.3 mi | ★★★★★ | 0 | 0 |
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