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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at San Jose Healthcare & Wellness Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions did not receive scheduled evening medications on time due to a failure to communicate changes in nursing assignments. Confusion among LVNs about who was responsible for the resident's care led to delayed administration of medications, including insulin, and incomplete documentation of medication times.
The facility failed to ensure proper use of bed rails for six residents, lacking care plans, physician's orders, or informed consent. This oversight was confirmed by the DON and violated the facility's policy, potentially placing residents at risk of entrapment and injury.
The facility's kitchen staff failed to properly test the dish machine sanitizer, using an incorrect method that involved dipping a test strip directly into the water. This practice was confirmed by the RD and DM, but contradicted by a dish machine vendor technician who stated the correct procedure involves using a cleaned plate or the inside walls of the dish machine. This failure risked exposing 51 residents to foodborne illness.
The facility failed to maintain sanitary conditions in the kitchen, with a dirty sink drainage pipe and unlabeled or expired food items, posing potential food contamination risks for residents. The sink drainage pipe was not included in the cleaning schedule, and food items like sugar-free gelatin and non-dairy creamer were improperly labeled or stored, contrary to facility policies.
The facility failed to ensure proper infection control procedures, as staff did not perform hand hygiene before patient contact or meal handling, and did not clean equipment before wound care. These lapses were acknowledged by the staff involved, contrary to CDC guidelines and facility policies.
A resident with dementia and other health conditions experienced verbal abuse when a Dietary Manager shouted at them for expressing hunger. The incident was witnessed by a state surveyor, who observed the manager attempting to close the door on the resident while shouting. Facility policies emphasize respectful treatment of residents, which was not followed in this case.
A resident's dignity was compromised during wound care when an LVN exposed the resident's back and buttocks by opening the room door without covering them. The LVN called for assistance twice without ensuring the resident's privacy, contrary to the facility's policy on resident rights.
The facility failed to obtain informed consent for psychotropic medications for three residents, compromising their right to be fully informed about their care. Incomplete documentation and missing signatures were noted for medications like Risperidone and Valproic Acid, contrary to facility policy.
A resident with Parkinson's, schizoaffective disorder, and dementia was left with unattended medication despite not being approved for self-administration. A nurse confirmed leaving the medication without observing the resident taking it, contrary to facility policy requiring licensed nurse administration.
The facility failed to follow physician orders and resident care plans for three residents. A resident did not receive prescribed dietary items, another did not have necessary physical supports applied, and a CNA was unaware of a resident's dialysis site, leading to potential care issues.
A facility failed to ensure complete medication administration for a resident via a gastrostomy tube. An LVN prepared and administered 12 medications, but residue remained in 6 medication cups, indicating incomplete dosing. The LVN acknowledged the issue, and the DON confirmed the resident did not receive the full prescribed dose, contrary to the facility's medication administration policy.
The facility failed to store and label medications properly, as observed during an inspection. An unopened bottle of Latanoprost eye drops and a Humalog insulin vial were not refrigerated as required, and a Breo Ellipta inhaler lacked an open date. RN E confirmed these storage and labeling errors, which violated the facility's policy to follow manufacturer's recommendations.
Two residents with intact cognition signed arbitration agreements without understanding them, as the facility failed to explain the agreements during admission. The admission director acknowledged the oversight, which violated the facility's policy requiring clear explanation of such agreements.
The facility did not meet the required minimum space of 80 square feet per resident in 10 bedrooms, with some rooms providing as little as 69 square feet per resident. Despite this, nursing care and services were not negatively impacted, and no complaints were reported by residents or staff.
A resident with skin infections did not receive prescribed medications due to a failure in the facility's medication management. Despite the medications being delivered, nurses documented them as on order and did not administer them, potentially compromising the resident's health.
A facility failed to maintain complete and accurate medical records for a resident when a nurse did not document notifying the physician about multiple medications that were not administered. The resident had orders for several topical medications, which were not documented as given on certain days. The nurse confirmed the medications were not administered due to unavailability and admitted to not documenting the physician notification, contrary to facility policy.
The facility failed to adhere to professional standards of practice when two residents were involved in an altercation. Staff did not complete necessary documentation or notify relevant parties, and a skin assessment was not performed. Additionally, there was no follow-up documentation after a resident's room change, contrary to facility policy. These deficiencies could negatively impact resident well-being.
The facility failed to notify the Ombudsman of discharges and transfers for three residents, as required by policy and state regulations. A resident was discharged without proper notification to the Ombudsman, and two other residents were transferred to an acute hospital without documentation of notification. The facility's policy mandates notification to the Ombudsman, which was not adhered to, as confirmed by the lack of documentation and confirmation.
The facility did not follow its Oxygen Therapy policy for two residents with chronic respiratory failure. One resident's nasal cannula was not labeled or dated, contrary to the policy requiring weekly changes and labeling. Another resident's room lacked a 'No Smoking' sign, which is required where oxygen is administered. These deficiencies were confirmed by an LPN and had the potential to compromise resident safety.
Failure to Communicate Nursing Assignment Results in Delayed Medication Administration
Penalty
Summary
The facility failed to establish and communicate which licensed nurse was responsible for providing care to a resident during the evening shift. On the specified date, there was confusion among the nursing staff regarding the assignment of care for the resident. Although the monthly nursing assignment indicated that one LVN was scheduled to provide care, it was requested that this nurse not care for the resident, and another LVN was supposed to assume responsibility. However, this change was not communicated to the replacement nurse, resulting in a lack of clarity about who was responsible for the resident's care during that shift. As a result of this miscommunication, the resident did not receive scheduled medications, including lactobacillus, metformin, metoprolol, and insulin lispro, at the appropriate times. The insulin was administered almost two hours late by the nurse supervisor, and the administration times for the other medications were not documented. The resident had multiple diagnoses, including dementia, diabetes mellitus, hypertensive heart disease, and heart failure, which required timely medication administration. The facility's policies required medications to be administered within one hour before or after the scheduled time, which was not followed in this instance.
Failure to Ensure Proper Use of Bed Rails
Penalty
Summary
The facility failed to ensure the proper use of bed rails for six residents, which included not having care plans, physician's orders, or informed consent for their use. Specifically, residents 31, 33, and 35 did not have care plans for the use of siderails. Residents 42 and 49 lacked both a physician's order and a care plan for siderails. Resident 37 was missing a consent, a physician's order, and a care plan for the use of siderails. These omissions were confirmed during an interview with the Director of Nursing, who acknowledged the lack of necessary documentation and care planning. The facility's policy, NP120 Bed Rails, requires an evaluation of the resident's need for bed rails, informed consent from the resident or their representative, and the development of a care plan regarding their use. The absence of these critical steps had the potential to place residents at risk of entrapment and injury, as the proper procedures for assessing and documenting the need for bed rails were not followed. Observations on a specific date confirmed that these residents had bilateral siderails without the required documentation and planning.
Improper Testing of Dish Machine Sanitizer
Penalty
Summary
The facility failed to ensure that the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice. During an observation, the kitchen staff incorrectly demonstrated how to test the dish machine sanitizer by dipping a test strip directly into the water from the dish machine. This method was confirmed by the Registered Dietician and Dietary Manager as their standard practice. However, a dish machine vendor technician specialist clarified that the correct procedure involves using a cleaned plate or the inside walls of the dish machine to test the sanitizer, not directly dipping the strip into the water. The facility's policy and procedure documents, which were not provided upon request, indicated that the dish machine should be used according to the manufacturer's guidelines. This failure had the potential to expose 51 residents to contaminants in food, increasing the risk of foodborne illness.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in the kitchen, leading to potential food contamination risks for 51 residents. During an initial kitchen tour, it was observed that the sink drainage pipe had a buildup of whitish to yellowish substances, and the sink faucet was dripping and could not be turned off completely for one or two weeks. The Dietary Manager confirmed that the drainage pipe was not included in the cleaning schedule, and a work order had been requested for the faucet. The Regional Registered Dietician verified that the cleaning log did not include the sink and drainage pipe, and it was recommended to add the sink to the cleaning log. The facility's policy and procedure indicated the maintenance of sanitation and safety standards, which were not adhered to in this instance. Additionally, during the kitchen tour, it was found that food items were improperly stored. A container of sugar-free gelatin was labeled with a past use-by date, and an opened non-dairy creamer and lettuce salad mix were stored without labeled open dates. The Registered Dietician confirmed that refrigerators were checked every morning and that the non-dairy creamer should be labeled with the date it was opened. The lettuce salad mix was wilted and needed to be discarded. The facility's policy required all food items to be labeled and dated, which was not followed, leading to potential food safety issues.
Infection Control Lapses in Hand Hygiene and Equipment Cleaning
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed by staff, as observed in several instances. Licensed Vocational Nurse D did not perform hand hygiene before checking the vital signs of Resident 21, despite acknowledging the necessity of such a practice. This oversight was noted during an observation and interview, where LVN D confirmed the lapse in protocol. The Centers for Disease Control and Prevention (CDC) guidelines recommend hand hygiene immediately before patient contact, which was not adhered to in this case. Additionally, during a dining observation, Certified Nursing Assistant C did not sanitize her hands before feeding Resident 40. Similarly, Licensed Vocational Nurse A and Registered Nurse F failed to wash or sanitize their hands before opening meal plate lids to check residents' meals. These actions were acknowledged by the staff involved, who admitted to not following the facility's policy requiring hand hygiene before meal distribution. Furthermore, LVN A did not clean scissors before using them to cut a granufoam dressing and vacuum-assisted closure tape for Resident 31's wound, which was also against CDC recommendations for infection control during wound care.
Verbal Abuse Incident Involving Resident's Hunger
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a staff member shouted at the resident and did not acknowledge the resident's statement of hunger. The incident involved a resident with a history of unspecified dementia, type 2 diabetes mellitus with diabetic chronic kidney disease, and major depressive disorder. The resident, who had a moderate cognitive impairment, was observed by a state surveyor holding a kitchen door slightly open and stating they were hungry. The Dietary Manager was seen shouting at the resident to go to their room and attempted to close the door on the resident. This interaction was witnessed by the surveyor, who noted that the Dietary Manager stopped shouting once they noticed the surveyor's presence. The facility's policies and job descriptions emphasize the importance of treating residents with respect and protecting their rights. However, during interviews, it was revealed that the Dietary Manager did not provide an appropriate response to the resident's statement of hunger. The Regional Registered Dietician and the Director of Nursing both indicated that staff should respond to residents' needs respectfully and appropriately. The facility's documents also prohibit rude or unprofessional behavior towards residents, highlighting a failure to adhere to these standards in this incident.
Resident Dignity Compromised During Wound Care
Penalty
Summary
The facility failed to uphold the dignity of a resident during a wound treatment procedure. The incident involved a licensed vocational nurse (LVN) who, while attending to a resident's wound care, exposed the resident's back and buttocks to the room door. The resident was lying in bed with the curtain fully open and the door closed. During the procedure, the LVN discovered that the resident had a bowel movement and, without covering the resident, opened the door to call a certified nursing assistant (CNA) for assistance. The LVN repeated this action when further help was needed, again without covering the resident. The LVN later acknowledged that she should have covered the resident before opening the door. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to properly obtain informed consent for psychotropic medications for three residents, which compromised their right to be fully informed about their care and treatment. Resident 20 had a physician's order for Risperidone, but the informed consent documentation was incomplete, lacking details such as medication name, dose, frequency, indications, side effects, and possible adverse reactions. Additionally, the verification of informed consent for Risperidone was missing a date and a nurse's signature. The facility's policy requires informed consent to be obtained prior to treatment, but this was not adhered to in this case. Resident 4's clinical record showed a physician's order for Valproic Acid to manage mood disorder, but there was no informed consent for this medication. The DON confirmed the absence of informed consent for Valproic Acid, although there was one for Seroquel. Similarly, Resident 28's informed consent documentation for Risperidone was incomplete, missing critical information such as medication name, dose, frequency, indications, side effects, and possible adverse reactions. The verification of informed consent for Risperidone also lacked a date and a nurse's signature. These deficiencies indicate a failure to ensure residents or their responsible parties were fully informed about their treatment options.
Medication Mismanagement for Non-Approved Self-Administration
Penalty
Summary
The facility failed to ensure that medications were not left unattended at the bedside for a resident who was not approved to self-administer medications. Resident 4, who has diagnoses including Parkinson's Disease, schizoaffective disorder, and dementia with agitation, was observed with a medication cup containing five pills left on her breakfast tray. The resident stated that staff routinely leave her medications for her to take on her own, despite not being approved for self-administration. During an interview, a registered nurse confirmed that she left the medication in the resident's room after the resident indicated she would take it later. The nurse did not stay to observe whether the resident took all of the prescribed medications. The Director of Nursing confirmed that Resident 4 was not approved for self-administration of medications. The facility's policy requires that medication be administered by a licensed nurse and upon the order of a physician or licensed independent practitioner.
Failure to Follow Physician Orders and Resident Care Plans
Penalty
Summary
The facility failed to provide necessary care and services for three residents, as observed during a survey. Resident 3 did not receive yogurt, tofu, orange, and tangerine with his meals as ordered by the physician. This was confirmed by the registered dietician and the director of nursing, who acknowledged that the physician's order should be followed. The facility's policy indicated that resident preferences should be reflected in the medical record and tray-card and updated in a timely manner. Resident 21 did not have rolled towels applied to his hands or offloading boots on his lower extremities as ordered by the physician. This was observed during multiple shifts, and the licensed vocational nurse acknowledged the oversight. Additionally, CNA C was unaware of Resident 23's dialysis site, incorrectly stating it was on his chest, and mentioned taking blood pressure on the arm with an AV shunt, which contradicts the facility's policy prohibiting such procedures on the arm with an AV shunt.
Incomplete Medication Administration via Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that medications were fully administered as prescribed for a resident during a medication pass administration. During the observation, a Licensed Vocational Nurse (LVN) prepared the resident's medications for administration via a gastrostomy tube. The LVN crushed each medication separately, placed them into individual medicine cups, and added approximately 10 milliliters of water per cup. After confirming that the resident had 12 medications, the LVN administered each medication separately, flushing the gastrostomy tube with 10 milliliters of water between doses. However, medication residue remained in 6 of the 12 medication cups after administration. In a concurrent interview, the LVN confirmed that residue remained in the six medication cups and acknowledged that more water should have been added to ensure all medication was administered. The Director of Nursing later acknowledged that the resident did not receive the full prescribed dose because medications remained in the medication cups. The facility's policy indicated that medications and treatments should be administered as prescribed to ensure compliance with dose guidelines.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications and biologicals according to manufacturer instructions and facility policy, as observed during an inspection of the medication cart in Station 2. Specifically, an unopened bottle of Latanoprost eye drops for a resident was found in the top drawer of the medication cart instead of being refrigerated as required by the pharmacy label. Additionally, an inhaler, Breo Ellipta, for another resident was opened but lacked an open date on the label, which is necessary to ensure proper tracking of the medication's usage. Furthermore, an unopened Humalog insulin vial for a third resident was stored in the medication cart rather than being refrigerated as indicated by the pharmacy label. During an interview, Registered Nurse E confirmed that the Latanoprost eye drops and Humalog insulin vial should have been refrigerated until opened, and the Breo Ellipta inhaler should have been labeled with an open date upon first use. The facility's policy, dated April 2008, mandates that medications and biologicals be stored safely, securely, and properly, following manufacturer's recommendations, which was not adhered to in these instances.
Failure to Explain Arbitration Agreement to Residents
Penalty
Summary
The facility failed to adequately explain the arbitration agreement to two residents, Resident 23 and Resident 31, during their admission process. Both residents, who had intact cognition as indicated by their Minimum Data Set assessments, signed the arbitration agreements without a full understanding of what they entailed. Resident 23 was admitted and signed the agreement on January 20, 2025, while Resident 31 signed on January 22, 2025. During interviews conducted on March 5, 2025, both residents stated that they were not informed about the arbitration agreement and simply signed the documents provided to them by the facility. The admission director, who was responsible for overseeing the arbitration agreements, stated in an interview on March 7, 2025, that she would ensure the agreements were explained to residents. However, the facility's policy, AD 17 Arbitration Agreements, dated May 26, 2023, clearly required that the agreement be explained to residents in a manner they understand, including in a language they comprehend. This policy was not followed, leading to the deficiency where residents signed the agreements without proper explanation or understanding.
Deficiency in Resident Room Space Requirements
Penalty
Summary
The facility failed to ensure that 10 bedrooms met the required minimum space of 80 square feet per resident. The specific room measurements were recorded, showing that several rooms had less than the required space, with some rooms accommodating three residents with as little as 69 square feet per resident. Despite this deficiency, observations during the survey indicated that nursing care and services were not negatively impacted by the shortage of space. Interviews with residents and staff revealed no complaints or concerns regarding the lack of space.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician, which had the potential to compromise the resident's health and well-being. The resident, who was admitted with diagnoses including cellulitis and other skin disorders, had physician orders for several topical medications to be applied multiple times a day. However, the medication administration record (MAR) and treatment administration record (TAR) for the resident showed that these medications were not documented as administered on specific dates. Instead, the nurses documented a code indicating that the medications were on order, suggesting they were not available for administration. Interviews with the licensed nurses responsible for administering the medications revealed that they were unable to find the medications in the facility and thus did not administer them. Despite their documentation indicating the medications were on order, a review of the facility's delivery records confirmed that the medications had been delivered before the first doses were due. This discrepancy between the delivery records and the nurses' documentation highlights a failure in the facility's medication management process, as the medications were available but not administered as prescribed.
Incomplete Medical Record Documentation for Medication Administration
Penalty
Summary
The facility failed to ensure the medical record was complete and accurate for a resident when there was no documentation that the nurse notified the resident's physician of multiple medications that were not administered. The resident, who was admitted with diagnoses including cellulitis and other skin disorders, had physician orders for several topical medications to be applied multiple times a day. However, on specific dates, these medications were not documented as administered in the resident's medication administration record (MAR) and treatment administration record (TAR). During an interview, a licensed nurse confirmed that he did not administer the medications because he could not find them in the facility. Furthermore, there was no documentation in the resident's medical record indicating that the nurse notified the physician about the missed medications. Although the nurse stated he had notified the physician, he admitted to not documenting this communication, acknowledging that documentation was required. The facility's policy on medical record completion emphasized the importance of prompt, complete, and accurate documentation, including notifying physicians about changes in a resident's condition.
Failure to Document and Follow Up After Resident Altercation and Room Change
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for two residents involved in an altercation. Staff did not complete an SBAR communication tool, nor did they notify the physician and responsible party when the altercation occurred. Additionally, a licensed nurse failed to perform a skin assessment on one resident after the incident, and neither resident was placed on alert charting for close monitoring and documentation for 72 hours following the altercation. These actions were not in line with the facility's policies, which require documentation and notification in such incidents. Furthermore, the facility did not follow up with one resident after a room change, failing to document the resident's adjustment to the new room and interactions with the new roommate. The facility's policy mandates that social services or a designee should assess and document the resident's adjustment for three days following a room change. The lack of documentation and follow-up in these instances had the potential to negatively affect the residents' health, safety, and well-being.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to notify the Ombudsman of discharges and transfers for three residents, which is a requirement under the facility's policy and state regulations. Resident 1 was discharged from the facility after her insurance issued a last covered date, but there was no documentation that the Ombudsman was notified of her discharge. The Director of Nursing (DON) attempted to provide evidence of notification but was unable to produce a fax confirmation or any documentation indicating that the Ombudsman was informed. An Ombudsman office representative confirmed that they had not received notifications of transfers and discharges from the facility since July 2023. Similarly, Residents 2 and 3 were transferred to an acute hospital, but there was no documentation in their medical records indicating that the Ombudsman was notified of these transfers. The facility's policy requires that a Notice of Transfer and Discharge be provided to the resident, responsible party, and Ombudsman 30 days prior to the transfer or discharge, or as soon as practicable in emergency situations. The facility did not adhere to this policy, as evidenced by the lack of documentation and confirmation of notification to the Ombudsman.
Failure to Follow Oxygen Therapy Policy for Two Residents
Penalty
Summary
The facility failed to adhere to its Oxygen Therapy policy for two residents who required oxygen therapy. Resident 4, diagnosed with chronic respiratory failure, was observed receiving oxygen via a nasal cannula that was neither labeled nor dated. According to the facility's policy, nasal cannulas should be changed weekly and labeled with the date of change. During an interview, a licensed nurse confirmed the oversight, acknowledging that the nasal cannula was not labeled with a date, which is a requirement per the facility's policy. Additionally, Resident 5, also diagnosed with chronic respiratory failure, was observed receiving oxygen without a 'No Smoking' sign posted in or at the entrance of her room. The facility's policy mandates that 'No Smoking' signs be prominently displayed wherever oxygen is stored or administered. Observations confirmed the absence of such signage, and a licensed nurse verified this deficiency, stating that the signs should be posted for residents using oxygen. These lapses in following the facility's policy had the potential to compromise the residents' health and safety.
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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) |
|---|---|---|---|---|
| Vista Manor Nursing Center | 2 mi | ★★★★★ | 0 | 0 |
| Canyon Springs Post-acute | 2.1 mi | ★★★★★ | 1 | 0 |
| Mission De La Casa | 3.2 mi | ★★★★★ | 0 | 0 |
| The Redwoods Post-acute | 3.3 mi | ★★★★★ | 2 | 0 |
| Skyline Healthcare Center - San Jose | 3.5 mi | ★★★★★ | 1 | 0 |
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