Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Skyline Healthcare Center - San Jose during CMS and state inspections, most recent first.
A resident with vertebral osteomyelitis and coccyx/left buttock wounds, cognitively intact per BIMS, reported that an LVN repeatedly punched, slapped, and squeezed his wound during ordered dressing changes, once captured on video showing the LVN making a fist and striking the wound through the dressing, causing the resident to cry out in pain. The resident also stated the LVN sometimes left him with pants down, curtain and door open, causing humiliation. Another resident corroborated witnessing the LVN hit, squeeze, or slap the wound and strike him across the backside. These actions occurred despite a facility abuse prevention policy stating residents have the right to be free from abuse and that administration will protect residents from abuse by anyone.
Surveyors found that food items, including cottage cheese past their use-by dates and unlabeled beverages, were improperly stored in facility refrigerators, some of which were operating at temperatures above the required range. Staff confirmed that these practices did not meet facility policies for food safety, labeling, and timely disposal.
Two dumpsters were found overfilled with garbage and their lids not fully closed, with additional trash bags left outside the covered dumpsters. Both the maintenance assistant and maintenance director confirmed that dumpsters should not be overfilled and all trash should be placed inside covered units, in accordance with facility policy and FDA Food Code requirements.
Staff were observed standing while feeding a resident instead of sitting at eye level, and two residents waited for their meal trays while another at the same table was already eating, contrary to facility policy. Additionally, a resident's urinary drainage bag was left uncovered and visible. These actions did not uphold resident dignity and comfort as required.
Several residents who were alert and cognitively intact reported not knowing the results of previous state surveys or the location of the survey binder. Key staff, including the Activity Director, were also unaware of the binder's location. Facility policy required survey results to be accessible and communicated to residents, but this was not done, as confirmed by interviews and record review.
Two LVNs did not wear gloves while handling a hazardous medication, despite clear labeling and facility policy requiring PPE use. Additionally, a resident with paraplegia did not have weekly weight monitoring as ordered by the physician, with the last weight recorded more than a month prior. Both deficiencies were confirmed by supervisory staff and were not in accordance with facility policies.
A review of medication records revealed that staff failed to accurately document the administration and removal of controlled medications for several residents. In some cases, medications were recorded as given in the MAR but not signed out in the CDR, while in other cases, medications were signed out in the CDR but not documented in the MAR. These discrepancies were confirmed by staff interviews and record reviews, resulting in inaccurate accountability of controlled substances.
Surveyors found that medications and biologicals were improperly stored, with different routes of administration and both active and discontinued drugs kept together in a medication room bin, and opened bottles of normal saline left unattended at the bedside tables of two residents. Staff confirmed these practices were not in line with facility policy, which requires proper storage and restricted access to medications.
Surveyors identified multiple infection control lapses, including used urinals and soiled linens improperly stored, medical equipment covered with used items, and improper storage of suction devices. A resident with a biliary catheter did not have required enhanced barrier precaution signage or PPE at the room entrance. Staff, including a treatment nurse and two kitchen employees, were observed not wearing face masks properly during wound care and food preparation. These deficiencies were confirmed by staff and were not in accordance with facility policy.
Surveyors observed that the dishwashing area floor was very wet and lacked a caution sign to warn staff or others entering the kitchen. Both the dietary manager and registered dietitian confirmed that safety signage should have been present, and facility policy requires prompt use of wet floor signs to maintain a safe environment.
The facility did not ensure that laundry staff consistently documented the cleaning of dryer lint as required by facility policy, with logs left blank for several hours on multiple days. The housekeeping supervisor and infection preventionist confirmed the expectation for hourly documentation, but records showed noncompliance.
A resident with epilepsy and developmental disorders was found asleep with her call light button on the floor, making it inaccessible. An LVN confirmed the inaccessibility and acknowledged the need for a more appropriate device, as required by facility policy for residents unable to use the standard call system.
Two residents were not given a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) when Medicare Part A services were discontinued, despite having benefit days remaining and continuing to reside in the facility. Facility records and staff confirmed that the required notice was not provided, as mandated by CMS guidelines.
A resident did not have an annual MDS assessment completed within the required timeframe. Review of the medical record and confirmation by the MDS Coordinator showed that the assessment was missed, in violation of CMS requirements for annual comprehensive assessments.
Two residents' MDS assessments were inaccurately coded: one resident's multiple falls were not recorded, and another resident's tobacco use was omitted, despite documentation in their medical records and assessments. MDS Coordinators confirmed these errors during record review.
Two residents were admitted without timely development of required baseline care plans. One resident with significant communication deficits did not have a communication care plan initiated, and another resident with a cancer diagnosis was not assessed for activities and lacked an activity care plan. Staff interviews and record reviews confirmed that these baseline care plans were not created within 48 hours of admission, as required by facility policy.
Two residents did not have their care plans properly updated: one resident's care plan was not revised after multiple falls and changes in cognitive status, and another resident's care plan for an antibiotic remained active after the medication was completed. These lapses were confirmed by the ADON and DON, and were not in accordance with facility policy requiring timely care plan updates.
A resident with a diagnosis of malignant neoplasm was found using bilateral half side rails without a physician's order, as required by facility policy. The resident was confused and unable to answer questions, and review of medical records confirmed the absence of an order authorizing side rail use.
Two residents consistently received their lunch meals late and at a cold temperature, as confirmed by both resident interviews and direct observation. Lunch trays were delivered well after the facility's established meal service window, contrary to policy and staff confirmation of expected meal times.
A resident with Type 2 diabetes did not receive timely insulin and the correct dosage of Myfortic due to a nurse's failure to follow physician orders. Insulin was administered late, and blood sugar checks were delayed, while only one of three prescribed Myfortic tablets was given on time. The DON confirmed these lapses, which were against the facility's medication administration guidelines.
A registered nurse left medications unattended on a bedside table in a resident's room. The resident, diagnosed with dementia and anxiety disorder, was not present at the time. The medications, vitamin B-12 and gabapentin, were left without supervision, contrary to the facility's policy requiring controlled storage accessible only to authorized personnel.
Two residents with psychiatric conditions did not receive necessary follow-up psychiatric services as recommended in their care plans. Despite evaluations indicating the need for follow-up within two to four weeks, the facility failed to provide these services, as confirmed by the social service assistant and assistant director of nursing. This oversight was contrary to the facility's policy on maintaining residents' mental and psychosocial well-being.
The facility failed to maintain an effective pest control program, with ongoing cockroach sightings in residents' rooms, nursing stations, and the kitchen. Despite a plan of correction requiring immediate treatment upon sightings, only weekly treatments were documented. Staff and residents reported seeing cockroaches, and observations confirmed unclean conditions. The administrator acknowledged the issue as an ongoing project, but the facility's policy for immediate action was not effectively implemented.
The facility failed to properly dispose of kitchen refuse, as observed when a garbage disposal bin was found without its lid, leaving refuse exposed. This was confirmed by the RD, who stated the bin should have been closed. The facility's policy requires waste to be kept in a tightly closed container, aligning with the FDA's 2022 Food Code.
A facility failed to ensure a pest-free environment, as evidenced by fruit flies in a resident's room and hallway. A nurse and CNA observed flies due to old food, but the maintenance supervisor confirmed no reports were made, contrary to the facility's pest control policy.
The facility failed to ensure proper pain management for a resident by not following physician orders for PRN medications, not updating the care plan, and using an incomplete pain scale. The resident had multiple diagnoses, including spinal stenosis and schizoaffective disorder, and experienced various levels of pain that were not adequately managed.
Failure to Prevent Physical Abuse During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical abuse during wound care. The resident had osteomyelitis of the vertebra and physician’s orders for treatment of a coccyx pressure injury and a left buttocks open wound, including cleansing with normal saline or Dakin’s solution, application of Santyl ointment, collagen, calcium alginate, and foam dressings twice daily or as needed. During wound treatment, a licensed vocational nurse (LVN A) was observed on a video recording provided by the resident standing on the left side of the bed while the resident lay face down. After pressing down the tape around the wound dressing with his gloved fingers, LVN A made a fist with his right hand and punched the resident’s wound on top of the dressing, causing the resident to scream in pain and shout obscenities. In interviews, the resident reported that prior to setting up the video recording, LVN A had punched his wound three or four times and, on other occasions, slapped the wound. The resident stated he was afraid to report LVN A and described that sometimes LVN A would perform the wound treatment, then leave the room with the resident’s pants down, the curtain open, and the door open, which the resident found humiliating. Another resident corroborated the abuse, stating he witnessed LVN A hitting, squeezing, or slapping the resident’s wound multiple times and also hitting him across the backside. The facility’s abuse prevention policy states that residents have the right to be free from abuse and that administration will protect residents from abuse by anyone, but the described actions of LVN A toward the resident’s wound and exposure during care constituted abuse that was not prevented.
Improper Food Storage, Labeling, and Temperature Control
Penalty
Summary
Surveyors observed multiple failures in food storage and handling within the facility. During inspections of medication rooms and the kitchen, refrigerators designated for resident food storage were found to be operating at temperatures significantly above the required range, with one refrigerator consistently reading 60 degrees Fahrenheit despite being closed for extended periods. Additionally, food items such as a pitcher of pinkish-red fluid and an unopened container of applesauce were stored in these refrigerators. The nurse supervisor confirmed that the refrigerator temperature should be maintained between 35 and 41 degrees Fahrenheit, as per facility policy. Furthermore, ten cups of cottage cheese past their use-by dates were found in the kitchen refrigerator, and both the dietary manager and registered dietitian verified that these items should have been discarded according to policy. Further observations revealed improper labeling and dating of food and beverages. In medication storage rooms, surveyors found a pitcher with brown-colored fluid with no label and an open container of thickened water that had exceeded the 24-hour discard guideline. Another refrigerator contained a pitcher of pinkish-red fluid that was not labeled. Facility policies require all food and beverages in refrigerators to be clearly labeled and dated, and to be discarded within specified timeframes. These deficiencies were confirmed by staff during interviews and were documented as not being in accordance with professional standards for food safety.
Improper Storage and Disposal of Garbage in Dumpsters
Penalty
Summary
Two out of four outside dumpsters at the facility were observed to be overfilled with garbage, with their lids not fully closed. Additionally, plastic bags containing trash were found outside the covered dumpsters rather than being placed inside. These conditions were confirmed during an observation and interviews with the maintenance assistant and maintenance director, both of whom acknowledged that dumpsters should not be overfilled and should remain properly covered, and that all trash should be placed inside the covered dumpsters. The facility's policy on pest control requires that the dumpster area be kept clean and lids remain closed. The United States Food and Drug Administration's 2022 Food Code also mandates that refuse be stored in receptacles with tight-fitting lids to prevent access by insects and rodents. The observed failure to comply with these requirements had the potential to attract pests, which could affect the 238 residents residing in the facility.
Failure to Maintain Resident Dignity During Meals and Personal Care
Penalty
Summary
Multiple deficiencies were identified related to the failure to maintain resident dignity and respect during mealtimes and personal care. Certified nursing assistant C was observed feeding a resident while standing over her, rather than sitting at eye level as required by facility policy. This was confirmed by both the nurse supervisor and the director of staff development, who stated that staff should sit at eye level to maintain resident comfort and dignity. The facility's policy on assisting residents to eat also specifies that staff should sit at eye level in front of the resident. In the dining room, two residents were observed waiting for their meal trays while another resident at the same table had already begun eating. Both residents confirmed they were hungry and had to wait while watching another resident eat. The activity director and assistant director of nursing acknowledged that meal trays should be served to all residents at the same table at the same time or in immediate succession, in accordance with the facility's policy to promote dignity and timely service. Additionally, a resident with an indwelling Foley catheter was observed with an uncovered drainage bag, making the contents visible. The infection preventionist confirmed that the drainage bag should have been covered for privacy. The facility's policy on dignity specifies that urinary catheter bags should be kept covered to promote resident well-being and self-esteem. These failures were observed to have the potential to affect the emotional and psychosocial well-being of the residents involved.
Failure to Inform Residents of Survey Results and Binder Location
Penalty
Summary
The facility failed to ensure that residents were aware of and reminded about the results of previous state recertification surveys, as well as the location of the binder containing these results. During a resident council meeting, five residents who were alert, oriented, and had intact cognition scores (BIMS scores ranging from 14 to 15) stated they did not know the results of the previous surveys or where the survey binder was located. These residents had various medical conditions, including acute respiratory disease, chronic pulmonary edema, atrial fibrillation, diabetes mellitus, peripheral vascular disease, cellulitis, hyperlipidemia, osteoarthritis, congestive heart failure, hemiplegia, hypertension, and seizures. Interviews with facility staff revealed further gaps in communication and knowledge. The Activity Director, who had been employed at the facility for twenty-five years, was unaware of the survey results and the location of the survey binder, suggesting it might be in the administrator's office. The administrator confirmed that the Activity Director should know the binder's location to inform and remind residents. The Director of Nursing also verified that all staff should be aware of the binder's location. A review of the facility's policy and procedure on access to survey results indicated that survey results and approved plans of correction should be available in a readable form and accessible to residents without needing to ask staff. The policy also stated that residents should be notified at least annually during Resident Council meetings, and meeting minutes should reflect that survey results were communicated. However, the findings showed that these procedures were not followed, as neither residents nor key staff were aware of the survey results or the binder's location.
Failure to Follow PPE Protocols and Physician Orders
Penalty
Summary
Two Licensed Vocational Nurses (LVNs) failed to wear proper Personal Protective Equipment (PPE), specifically gloves, while handling a medication labeled as a hazardous drug (Divalproex Sodium) for two residents. Both LVNs acknowledged that the medication packaging was marked with a hazardous drug label and admitted they should have worn gloves during administration. The Director of Nursing and Consultant Pharmacist confirmed that gloves are required when handling such medications, and the facility's policy mandates the use of appropriate PPE to minimize exposure to hazardous drugs. Additionally, a resident with a primary diagnosis of unspecified paraplegia had a physician's order for weekly weight monitoring every Saturday at 9:00 a.m. However, the resident's weight was not monitored as ordered, with the last recorded weight taken over a month prior to the review. The nursing supervisor and Director of Nursing both verified that the physician's order for weekly weight checks was not followed, and the facility's policy requires all physician orders to be carried out accurately and promptly.
Failure to Accurately Account for Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accountability of controlled medications for seven out of twelve residents reviewed during a random audit. Specifically, medications were documented as administered on the Medication Administration Record (MAR) for several residents, but the corresponding doses were not signed out on the Controlled Drug Record (CDR). For example, a resident with a physician's order for Methadone had three tablets unaccounted for in the CDR, and the nurse confirmed that while the medication was documented in the MAR, it was not signed out in the CDR. Similar discrepancies were found for residents receiving Lorazepam and Hydrocodone-Acetaminophen, where the medications were recorded as given in the MAR but not reflected in the CDR. Conversely, there were instances where medications were signed out of the CDR but not documented as administered in the MAR. This occurred with residents prescribed Oxycodone, Tramadol, and other controlled substances. In these cases, nursing staff removed the medications from the locked controlled medication compartment, signed them out in the CDR, but failed to document the administration in the MAR. The Director of Nursing (DON) acknowledged that these controlled medications were not accounted for in the MAR during concurrent interviews and record reviews. A review of the facility's policies and procedures confirmed that staff are required to document the administration of medications immediately in both the MAR and the CDR. The observed failures to follow these procedures resulted in inaccurate accountability of controlled medications, as confirmed by staff interviews and record reviews during the survey.
Improper Storage of Medications and Biologicals
Penalty
Summary
Surveyors identified that the facility failed to store medications and biologicals in accordance with its own policies and accepted professional standards. In one medication room, a clear plastic bin was found containing medications with different routes of administration, including liquid Lithium, Atorvastatin tablets, and a Symbicort inhaler, as well as both active and discontinued medications. The bin also contained house stock normal saline and wound dressings. The nurse supervisor and DON confirmed that these items should not have been stored together, and that discontinued medications should have been removed and disposed of per policy. Additionally, opened bottles of 0.9% sodium chloride (normal saline) were found unattended at the bedside tables of two residents. One resident had both a large and small bottle of normal saline at their bedside, and another had a used bottle of normal saline left at their bedside. The MDS Coordinator confirmed that these items were used for wound treatment and should have been stored in the treatment cart, not left unattended. Facility policy requires that medications and biologicals be stored properly and only accessible to authorized personnel.
Infection Control Lapses in Resident Care and Food Preparation
Penalty
Summary
Multiple infection control deficiencies were identified during observations, interviews, and record reviews within the facility. Used and uncovered urinals were found on bedside tables next to medical equipment such as spirometers, and suction devices were improperly stored, including a yankauer suction tube placed inside an open clean gloves box and a suction machine and nebulizer covered by a used wash basin. Soiled linens were observed on the floor, and urinals were left full and not emptied in resident rooms. These practices were confirmed by staff, including the assistant director of nursing and certified nursing assistants, who acknowledged that these items should have been stored or disposed of according to facility policy to prevent contamination and cross-infection. Further deficiencies included the lack of enhanced barrier precaution (EBP) signage and personal protective equipment (PPE) outside the room of a resident with a biliary catheter, despite facility policy requiring such measures for residents with indwelling devices. Staff interviews confirmed that EBP signage and PPE should have been present. Additionally, a treatment nurse was observed wearing a surgical mask below the nose during wound care, and two kitchen staff were not wearing their face masks properly while preparing food for the tray line. These lapses were acknowledged by the staff involved and by supervisory personnel, who confirmed that masks should cover both the nose and mouth during resident care and food preparation. Review of facility policies indicated requirements for proper storage and handling of soiled linens, urinals, and PPE use, as well as the need for EBP for residents with wounds or indwelling devices. The observed failures to follow these policies were confirmed by staff during interviews and were directly linked to the deficiencies cited in the report.
Failure to Provide Wet Floor Warning in Kitchen Dishwashing Area
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen's dishwashing area, as observed during an initial tour with the dietary manager. The floors in the dishwashing area were found to be very wet, and there was no caution or warning sign present to alert staff or individuals entering the area about the wet floor. This condition was directly observed by surveyors and acknowledged by the dietary manager during the tour. Further confirmation was provided during an interview with the registered dietitian, who verified that kitchen areas, including dishwashing areas, should always be kept safe and that signage for wet floors is necessary to warn staff. A review of the facility's undated Kitchen Safety policy indicated that all dietary and kitchen staff must follow established safety guidelines, including keeping walkways clear and promptly cleaning spills using wet floor signs. The lack of a warning sign and the presence of a wet floor constituted a failure to adhere to these established safety procedures.
Failure to Ensure Laundry Staff Compliance with Dryer Lint Cleaning Documentation
Penalty
Summary
The facility failed to maintain an effective infection control training program for laundry staff, specifically regarding the routine cleaning of dryer lint. Record review showed that the laundry lint cleaning log was left blank for several hours on multiple days, indicating that staff did not document or possibly did not perform the required cleaning during those times. The housekeeping supervisor confirmed the gaps in documentation and stated that the log served as proof of lint cleaning. The infection preventionist stated that laundry staff were required to check and document lint cleaning every hour. The facility's policy required lint traps to be cleaned after each load and for staff to document this action, but the logs did not reflect compliance with this policy on several occasions. No specific residents or their medical histories were mentioned in relation to this deficiency.
Call Light Inaccessibility for Resident with Special Needs
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the call light button for one resident was within reach and appropriate for her condition. The resident, who had a history of epilepsy, lack of coordination, psychological development disorder, and delayed childhood milestones, was observed asleep with her call light button on the floor. During a subsequent observation and interview, an LVN confirmed that the call light was not accessible and acknowledged that the resident should have had a device suitable for her needs. Review of the facility's policy indicated that residents unable to use the standard call system should be provided with an alternative means of communication, documented in the care plan.
Failure to Provide SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to two residents who were discharged from Medicare Part A services while still having benefit days remaining and continued to reside in the facility. For one resident, the medical record showed admission under Medicare Part A, with a planned discharge from these services while the resident remained in the facility. The facility's own documentation confirmed that the SNF ABN was not provided to this resident. Similarly, another resident was admitted under Medicare Part A, later discharged from these services with benefit days remaining, and continued to live in the facility without receiving the required SNF ABN. The interim social services director confirmed during an interview that the SNF ABN was not given to either resident. Facility records and CMS guidelines require that a SNF ABN be provided in such circumstances to inform residents of their financial liability and appeal rights when Medicare Part A services are discontinued. The failure to provide this notice was documented in the facility's records and confirmed by staff during the survey.
Failure to Complete Required Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual Minimum Data Set (MDS) assessment for one resident as required. Review of the resident's medical record showed that while an annual MDS assessment was completed in May of the previous year, there was no evidence of a completed annual MDS assessment for the following year. During an interview and concurrent record review, the MDS Coordinator confirmed that the annual assessment had not been completed within the required timeframe. According to the CMS RAI Manual, the annual MDS assessment must be completed at least every 366 days, and this requirement was not met for the resident in question.
Inaccurate MDS Coding for Falls and Tobacco Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents. For one resident with a history of falls, medical records and progress notes documented two separate incidents where the resident was found on the floor in her room. However, the MDS for this resident was coded to indicate that no falls had occurred during the specified time frame. The MDS Coordinator confirmed during record review that these falls should have been coded as 'Yes' in section J1800, in accordance with the RAI Manual instructions. For another resident with diagnoses including osteomyelitis and vertebral fractures, a Safe Smoking Assessment Evaluation documented that the resident smoked cigarettes. Despite this, the MDS was coded to indicate that the resident did not use tobacco. The MDS Coordinator confirmed that section J1300 should have been coded 'Yes' to reflect current tobacco use, as supported by the resident's assessment and the RAI Manual guidelines.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop resident-centered baseline care plans within 48 hours of admission for two residents. For one resident with a history of cerebral infarction, aphasia, gait abnormalities, and dysphagia, there was no communication problem care plan initiated upon admission or up to the time of the survey. Clinical records and interviews with the ADON and MDS Coordinator confirmed that the resident's MDS indicated significant communication deficits, yet no baseline care plan addressing these needs was created within the required timeframe. For another resident admitted with a primary diagnosis of malignant neoplasm of the breast, there was no baseline activity care plan developed, and no activity care plan was present at all. The resident's physician order allowed participation in activities as tolerated, but the activity director confirmed that the resident had not been assessed for activities and no baseline activity care plan was created within 48 hours of admission, as required by facility policy. These findings were verified through record review and staff interviews.
Failure to Revise and Update Care Plans for Two Residents
Penalty
Summary
The facility failed to revise and update comprehensive care plans to address the individual care needs of two residents. For one resident with diagnoses including schizophrenia, cerebral infarction, hemiplegia, and impaired cognition, the care plan interventions related to falls and cognitive function were not revised or modified after multiple falls and changes in cognitive status. The assistant Director of Nursing confirmed that the care plan had not been updated to reflect these changes, despite facility policy requiring care plans to be re-evaluated and modified as necessary to reflect changes in care, service, and treatment. For another resident with a history of intracerebral hemorrhage, kidney contusion, and sepsis, the care plan for an antibiotic remained active even after the antibiotic course was completed. The Director of Nursing confirmed that the care plan should have been resolved but was not. These failures were identified through interviews, medical record reviews, and review of facility policies and procedures, and placed the residents at risk of not receiving appropriate, consistent, and individualized care.
Failure to Obtain Physician Order for Bed Rail Use
Penalty
Summary
A deficiency occurred when a resident was observed using bilateral half side rails without a physician's order authorizing their use. The resident, who was admitted with a primary diagnosis of malignant neoplasm of the breast, was found lying in bed with the side rails up. The resident was confused and unable to answer questions at the time of observation. Review of the resident's medical records, including the physician order report covering the relevant period, confirmed that there was no documented physician's order for the use of side rails for this resident. Further review and interview with the nurse supervisor verified the absence of a physician's order for the side rails, despite facility policy requiring such an order, including documentation of diagnosis and medical necessity. The facility's policy treats side rails as physical restraints, necessitating a physician's order prior to use, which was not obtained in this case.
Delayed Meal Service Resulting in Cold Food
Penalty
Summary
The facility failed to ensure that two residents received their lunch meals in accordance with the scheduled meal times, as required by facility policy. Both residents reported that their food consistently arrived late and was cold. Observations confirmed that lunch trays for these residents were delivered significantly after the designated meal service window, with one tray arriving at 1:34 p.m. and another at 1:50 p.m., despite the policy stating that lunch should be served between 11:30 a.m. and 1:00 p.m. The dietary manager confirmed that the last lunch tray should be delivered by 1:00 p.m., and documentation supported the established meal times. These delays resulted in the residents receiving meals outside the scheduled period, with food that was not at an appetizing temperature.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for a resident diagnosed with Type 2 diabetes and other conditions, leading to a deficiency in care. The resident had specific orders for insulin administration and medication dosage, which were not followed correctly. On one occasion, insulin lispro was administered late, and the resident's blood sugar was not checked before lunch as required, resulting in delayed insulin administration. Additionally, the resident was prescribed Myfortic, a medication to prevent organ transplant rejection, to be taken in a specific dosage twice daily. However, the charge nurse administered only one out of the three prescribed tablets at a scheduled time, leading to a delay in the complete dosage being given. This deviation from the prescribed medication schedule was noted in the resident's progress notes and risk meeting notes. The Director of Nursing confirmed these lapses during an interview, acknowledging that the nurse responsible did not follow the physician's orders as documented. The facility's guidelines stipulate that medications should be administered within a specific timeframe relative to meal times, which was not adhered to in this case. These failures in following physician orders had the potential to impact the resident's health adversely.
Unattended Medications in Resident's Room
Penalty
Summary
The facility failed to store medications safely when a registered nurse left medications unattended on a bedside table in a resident's room. The resident, who was not present in the room at the time, had been admitted with diagnoses including dementia and anxiety disorder. The medications left unattended were vitamin B-12 and gabapentin, which were prescribed to the resident. During an observation, it was noted that the medications were left in a medication cup on the bedside table without supervision. The registered nurse responsible for the resident's care confirmed that she left the medications unattended while she was at the nurse's station preparing documents for another resident. The facility's policy on medication storage requires that medications be stored in a controlled environment accessible only to authorized personnel, which was not adhered to in this instance.
Failure to Provide Follow-Up Psychiatric Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to maintain the highest practicable mental and psychosocial well-being for two residents. Resident 1, diagnosed with obsessive-compulsive personality disorder, bipolar disorder, and major depressive disorder, was admitted to the facility and had a psychiatric evaluation on 6/22/23. The psychiatrist recommended a follow-up within two to four weeks, but no follow-up services were provided. Similarly, Resident 2, who was readmitted with a diagnosis of dementia, had an initial psychiatric evaluation on 4/7/22, which also recommended a follow-up within two to four weeks. However, no follow-up psychiatric services were provided for Resident 2 either. Interviews with the social service assistant and the assistant director of nursing confirmed that both residents should have continued receiving psychiatric services as per their psychiatric visit progress reports. The facility's policy and procedure on psychosocial well-being and behavioral health services stated that residents would receive necessary services to maintain their well-being in accordance with their comprehensive assessment and plan of care. The failure to follow up on the psychiatric services for these residents was acknowledged by the facility staff, indicating a lapse in adhering to the established care plans.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by ongoing sightings of cockroaches in various areas, including residents' rooms, nursing stations, the kitchen, and activity rooms. Despite having a plan of correction from a previous survey, which included immediate pest treatment upon sightings, the facility did not follow through with these actions. Weekly pest treatments were documented, but there were no records of immediate treatments following the identification of cockroaches. Staff and residents reported seeing cockroaches, and environmental observations confirmed the presence of pests and unclean conditions, such as food residuals and trash on the floors. Interviews with staff, including a licensed vocational nurse, registered nurse, housekeeping supervisor, dietary manager, and certified nursing assistants, revealed that cockroaches were a recurring issue. The administrator acknowledged that addressing the pest problem, particularly with German cockroaches, was an ongoing project. The facility's policy required routine inspections and immediate action upon pest sightings, but these procedures were not effectively implemented, leading to a failure in providing a sanitary environment for residents.
Improper Disposal of Kitchen Refuse
Penalty
Summary
The facility failed to properly dispose of refuse in the kitchen, as observed during a survey. At 10:55 a.m. on June 6, 2024, three garbage disposal bins were noted in the kitchen, with one bin having a folded box, a cup, two plastic food containers, and a metal food container placed on top of it. Another bin was found without its lid, leaving the refuse exposed to the air. This observation was confirmed by the registered dietitian (RD) during an interview at 11:13 a.m., who acknowledged that the garbage disposal bin should have been closed with its lid. The facility's policy and procedure on Sanitation and Infection Control, dated 2023, requires that kitchen waste not disposed of by mechanical means be kept in a clean, leak-proof, nonabsorbent, tightly closed metal or plastic container with a plastic liner. Additionally, the 2022 Food Code from the Food and Drug Administration specifies that waste handling for refuse should be kept covered. The failure to adhere to these guidelines had the potential to attract pests and affect the 238 residents in the facility.
Pest Control Deficiency Due to Unreported Fruit Flies
Penalty
Summary
The facility failed to maintain an environment free of pests, as evidenced by the presence of multiple flying insects in a resident's room and the hallway. On May 1st, a licensed vocational nurse reported numerous flies in a resident's room due to old food. Concurrently, a certified nurse assistant observed more than ten fruit flies in the same room, confirming the nurse's observation. On June 6th, two fruit flies were seen near bananas on the resident's over-the-bed table, and another fly was observed near the resident in the hallway. The maintenance supervisor confirmed that there were no reports of fruit flies in the resident's room from May 1st to June 6th, despite the facility's policy requiring insect sightings to be reported to the housekeeping/maintenance supervisor.
Failure to Follow Pain Management Protocols
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to pain management for one resident. The licensed nurses did not follow the physician's order to administer PRN pain medications based on the pain assessment documented. Additionally, the licensed nurses did not update the resident's care plan for pain management and administered the wrong medication for severe pain. The pain scale used did not include all pain levels, which could have contributed to improper pain assessment and management. The resident was admitted with diagnoses including generalized muscle weakness, cervical region spinal stenosis, major depressive disorder, and schizoaffective disorder. Despite having physician orders for Morphine and Tylenol for pain management, the licensed nurses failed to administer these medications as prescribed. The ADON confirmed that there was no documented evidence that the resident had refused the PRN pain medication. The care plan was not updated to include the PRN medication, and the pain scale used was incomplete, lacking levels 1, 3, 5, and 7.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 432 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| O'connor Hospital D/p Snf | 0 mi | ★★★★★ | 8 | 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.