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 San Jose Nursing Center during CMS and state inspections, most recent first.
The facility did not revise or update the comprehensive care plans for four residents, resulting in care plans that lacked current medical justifications, measurable timeframes, and appropriate interventions for devices such as side rails and Geri-chair restraints. Staff interviews and record reviews confirmed that care plans were outdated, missing necessary details, and not aligned with current physician orders or resident needs.
Nursing staff did not attempt less restrictive alternatives, failed to review risks and benefits, and did not obtain informed consent or complete required assessments before using bed rails for four residents, including individuals with cognitive impairment, physical disabilities, and psychiatric diagnoses. Required documentation and periodic reassessment were also lacking, as confirmed by interviews with the DON and ADON.
Dietary staff served meals that did not match the posted menu, made unapproved substitutions without maintaining a substitution log, and used outdated menus. The dietician had not reviewed or approved the current menus for several months, and updated menus were not posted or available. These failures affected all residents and did not comply with facility policy requiring dietician review and menu adherence.
Staff served cold chicken penne pasta salad and a mechanical vegetable mixture at temperatures above 41°F, contrary to professional standards and facility policy. The food was prepared earlier in the day, refrigerated, and then placed on ice, but did not reach the required cold holding temperature before being served to residents on regular and mechanical soft diets.
A resident with severe cognitive impairment, dementia, and muscular atrophy was found with her call light on the floor and not within reach, despite her care plan requiring it to be accessible and staff reminders to use it. Staff confirmed the call light was not accessible and acknowledged the resident needed reminders to use it, but the device remained out of reach after maintenance work, contrary to facility policy.
A MAR binder containing residents' medication information was left open and unattended on a medication cart in a hallway, allowing staff and visitors to view confidential information. An LVN admitted to stepping away briefly, and the DON confirmed that the binder should not have been left exposed.
A resident with cerebral palsy and moderate cognitive impairment was observed using a wheelchair with both armrests cracked and torn, exposing the padding. The maintenance worker, responsible for repairs, had not recently checked the wheelchair and was unaware of the issue due to lack of staff reporting. The DON confirmed that periodic checks and timely replacement of torn armrests were expected, but no policy for equipment maintenance was provided during the survey.
A resident with severe cognitive impairment and multiple chronic conditions was consistently placed in a Geri-chair with a tray table restraint whenever out of bed, without removal for meals or activities and without ongoing re-evaluation or documentation of the need for the restraint. Staff confirmed the restraint was always used for fall prevention and at the family's request, but records lacked evidence of less restrictive alternatives or regular assessment, resulting in a deficiency related to improper use of physical restraints.
A resident with severe cognitive impairment and multiple psychiatric diagnoses, including depression and psychotic disorder, was not referred for a Level I PASARR screening after being newly diagnosed with additional mental health conditions. The DON did not consult with the psychiatric NP or initiate the required referral, despite facility policy mandating PASARR coordination for residents with mental illness.
A resident with Parkinson's Disease and Dementia, who was bedbound and dependent on staff for all ADLs, did not receive assistance with washing her face or brushing her teeth as required. The resident reported feeling dirty and noted delays in staff response to her requests for help. CNAs confirmed that hygiene care was not provided that morning, and the DON acknowledged the resident's need for total care.
A resident with severe cognitive impairment and multiple diagnoses received scheduled DuoNeb nebulizer treatments, but the nebulizer mask was found uncovered, undated, and with a dried white substance present. Staff interviews revealed inconsistent documentation and lack of clarity regarding equipment maintenance, and the DON was unaware of the resident's ongoing respiratory treatments.
A resident's nutrition assessment form contained multiple inaccuracies, including incorrect admission date, date of birth, height, and ideal body weight range. The dietician made handwritten corrections to some information but was unaware of other errors, and also reported computer issues. The resident had severe cognitive impairment and significant weight loss, and the DON acknowledged that these documentation errors could affect the accuracy of dietary assessments.
A resident receiving hospice care did not have hospice services documented in her care plan or medical record, and hospice nursing visit notes were missing from both the hospice binder and facility records. Facility nurses were unaware that hospice documentation was required, and communication with the hospice provider was limited to verbal reports, resulting in incomplete records and potential gaps in care coordination.
Sixteen double occupancy rooms were found to have less than the required 80 square feet per resident, with measurements ranging from 61.9 to 79.3 square feet. Nineteen residents were residing in these rooms at the time of the survey, and the Administrator confirmed the deficiency, noting a waiver was in effect and room sizes had not changed.
The facility failed to implement policies to prevent abuse, neglect, and exploitation, as two staff members were not screened through required registries. Despite working shifts, NA A and NA B had not undergone annual background checks, violating facility policies and potentially affecting all residents.
The facility failed to verify that two nurse aides had completed the required training and certification before allowing them to work. Despite lacking documentation of their certification, both aides were scheduled and worked shifts. The administrator was aware of the situation, noting that one aide had failed the certification test and did not plan to retake it. This deficiency could impact all residents by having uncertified staff provide direct care.
The facility failed to provide required training on abuse, neglect, and exploitation reporting procedures to two staff members, NA A and NA B, for the year 2024. This deficiency was identified through a review of personnel files and in-service attendance records, revealing that both staff members did not attend the necessary training. Interviews with the DON and Administrator confirmed the oversight, highlighting a lapse in adherence to the facility's policy on staff training.
The facility failed to maintain resident assessments completed within the previous 15 months in the residents' active medical records. Six residents' MDS assessments were stored in a locked cabinet in the DON/Owner's office, making them inaccessible to staff when needed. The facility's leadership admitted they were unaware that these assessments should be part of the master record in the residents' active medical records.
The facility failed to ensure a safe, functional, sanitary, and comfortable environment in an adjacent building used for laundry, food storage, and maintenance. Observations revealed safety hazards, including improper handling of electrical cords and gas connections, storage of flammable materials, and exposed live electrical wires. The Administrator acknowledged the issues and stated that they would be corrected immediately.
A facility failed to ensure accurate MDS assessments for a resident, incorrectly listing psychiatric diagnoses not supported by the medical record. The DON/Owner admitted to the error, attributing it to the high volume of assessments being completed at the time.
The facility failed to develop and implement comprehensive person-centered care plans for two residents, resulting in one resident having no care plan and another having an incomplete care plan. The DON acknowledged missing documents due to chart thinning and OIG requests, and the facility lacks a specific Care Plan policy.
The facility failed to provide the required minimum of 80 square feet per resident in 16 double occupancy rooms, affecting 19 residents. The Administrator confirmed the deficiency and stated that a room waiver was in effect, although the room sizes had not changed.
Failure to Revise and Update Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to revise and update the comprehensive care plans for four residents as required, resulting in care plans that did not accurately reflect the residents' current medical conditions, interventions, or measurable timeframes. For one resident with severe cognitive impairment and functional limitations, the care plan for the use of a half side rail did not specify the medical condition necessitating the side rail, lacked measurable timeframes, and did not include reassessment for safe use. The Director of Nursing (DON) acknowledged that the care plan was not updated to reflect the resident's current needs, despite being aware of the requirement. Another resident with dementia, diabetes, and significant weight loss had a care plan that was not revised to reflect current dietary orders or interventions following the weight loss. The care plan contained outdated and undated handwritten notes, lacked measurable timeframes, and did not align with the resident's current physician orders for diet. Similarly, a third resident with vascular dementia and a history of amputation had a care plan for the use of a half side rail that did not document the medical reason for the side rail, did not include timeframes, and omitted the need for reassessment, as confirmed by the Assistant Director of Nursing (ADON). A fourth resident with dementia, hypertension, and diabetes was observed multiple times using a Geri-chair with a tray table, which functioned as a physical restraint. The care plan for this resident did not include interventions for removing the tabletop or assessing the continued need for the restraint, nor did it provide measurable timeframes for goals. Observations showed the resident was frequently in the Geri-chair with the tray table attached, and staff interviews confirmed the resident was always up in the chair with the tabletop. The facility was unable to provide a care plan policy when requested.
Failure to Assess, Obtain Consent, and Use Alternatives Prior to Bed Rail Use
Penalty
Summary
Nursing staff failed to follow required procedures before the use of side or bed rails for four residents. Specifically, staff did not attempt to use less restrictive alternatives prior to installing bed rails, did not review the risks and benefits of bed rail use with the residents or their representatives, and did not obtain informed consent in several cases. Additionally, assessments for the safe use of bed rails were either not completed or not documented as required. For one resident with severe cognitive impairment and impaired vision, the care plan included the use of a side rail for bed mobility, but there was no documentation of the risks and benefits, no evidence of less restrictive alternatives being tried, and the consent form was incomplete and unsigned by a physician. Another resident with moderate cognitive impairment and multiple psychiatric diagnoses had a physician's order and care plan for side rail use, but there was no consent or assessment for the use of the side rail, and the last assessment indicated no side rail was in use. A third resident with moderate cognitive impairment, cerebral palsy, and seizure disorder had a care plan and physician's order for side rail use, but lacked both a consent and an assessment for the device. The fourth resident, who had no cognitive impairment but had bilateral lower extremity amputations, used a side rail for mobility and repositioning, but the consent did not include risks and benefits, and there was no documentation of less restrictive alternatives or a current reassessment. Interviews with the DON and ADON confirmed that required procedures, including obtaining consent, assessing for safety, and periodic reassessment, were not consistently followed.
Failure to Follow, Update, and Review Menus by Dietician
Penalty
Summary
Dietary staff did not follow the posted menu for a lunch meal, serving pinto beans instead of the scheduled pirogues, without maintaining a substitution log or consulting the dietician about the change. The Food Service Supervisor (FSS) admitted to not posting the monthly menu at a glance, not keeping a substitution log for several months, and making menu changes based on personal assumptions about resident preferences. The FSS also used outdated menus from June 2024, as updated menus were not available or posted, and did not communicate menu changes to the dietician prior to implementation. The facility failed to ensure that the dietician reviewed or approved updated menus for approximately five months, as the updated menus were sent to a sister facility and not obtained by the administrator. The dietician confirmed she had not reviewed or signed the current menus and that dietary staff were using outdated menus without access to menu recipes, substitution options, or purchase guides. Facility policy required dietician approval of menus and adherence to nutritional standards, but these procedures were not followed, affecting the entire resident population.
Cold Food Items Served Above Safe Temperature Standards
Penalty
Summary
The facility failed to store, prepare, and serve cold food items in accordance with professional food service safety standards. Specifically, during the evening meal service, the chicken penne pasta salad and the mechanical vegetable mixture were served at temperatures above the required 41 degrees Fahrenheit. Observations showed that the chicken penne pasta salad was at 62 degrees F and the mechanical vegetable mixture was at 70 degrees F, despite being placed on ice in the steamtable. Staff interviews confirmed that these items were intended to be served cold and that the proper serving temperature should be 41 degrees F or below. The food had been prepared earlier in the afternoon and placed in the refrigerator, but did not reach the required temperature before being served. Further review of facility policy and the FDA Food Code confirmed that cold foods must be maintained at or below 41 degrees F. The Food Service Supervisor and other staff acknowledged the temperature requirements and the potential for food to go bad if not properly cooled. The deficiency was observed as the cold food items were served to residents on both regular and mechanical soft diets at temperatures above the required threshold, in direct violation of professional standards and facility policy.
Failure to Ensure Call Light Accessibility for Resident with Cognitive and Physical Impairments
Penalty
Summary
The facility failed to ensure that a resident's right to reasonable accommodation of needs and preferences was met, specifically regarding access to the call light. Observations revealed that the resident's call light was on the floor and not within reach, despite the care plan indicating that the call light should be kept within the resident's reach and that the resident should be reminded to use it for assistance. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and muscular atrophy, was severely cognitively impaired, required partial to moderate assistance for mobility, and was always incontinent of bowel and bladder. The resident was able to lift her left arm and grasp a hand when prompted, but her speech was garbled, making it unclear if she could effectively use the call light without reminders. Staff interviews confirmed that the call light was not accessible to the resident and acknowledged that it should not have been on the floor. Maintenance had been working on the call light earlier, but after their departure, the call light remained out of reach. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) both recognized that the resident could use the call light with verbal reminders and that not having it within reach could prevent the resident from receiving needed assistance. Facility policy required CNAs to attend to residents' needs at all times, but this was not followed in this instance.
Failure to Maintain Confidentiality of Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records when a Medication Administration Record (MAR) binder was left open and unattended on a medication cart in the west wing hallway. The open binder, which contained information on residents' prescribed medications and administration times, was visible to anyone passing by, including staff and visitors. This lapse occurred when an LVN stepped away from the cart to put away laundry, leaving the MAR binder exposed. Both the LVN and the Director of Nursing acknowledged that the MAR binder should not have been left open and unattended. The facility's medical records policy was requested but not provided by the time of the survey exit.
Failure to Maintain Wheelchair Armrests in Good Repair
Penalty
Summary
A deficiency was identified when a resident with cerebral palsy, moderate cognitive impairment, and impaired lower extremity range of motion was observed using a wheelchair with both armrests cracked and torn, exposing the padding. The resident's care plan noted a self-care deficit related to cognitive impairment, and the resident relied on the wheelchair for mobility. Multiple observations confirmed the poor condition of the wheelchair armrests over two days. Interviews with the maintenance worker revealed that he was responsible for replacing torn armrests but had not checked the resident's wheelchair recently and had not received reports from staff about the issue. The Director of Nursing stated that the maintenance worker was expected to periodically check wheelchairs for functionality and replace torn armrests to prevent potential skin tears. Despite requests, the facility was unable to provide a policy for maintaining resident equipment in good working order before the survey exit.
Failure to Ensure Resident Freedom from Unnecessary Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints imposed for convenience and not required to treat medical symptoms, as observed over a four-day survey period. The resident, an elderly female with diagnoses including dementia, hypertension, and diabetes, was consistently seated in a Geri-chair with a tray table attached whenever she was out of bed. The tray table was not removed during meals or activities, and there was no documentation of ongoing re-evaluation of the need for the restraint. Staff interviews confirmed that the tray table was always used when the resident was out of bed, and alternative interventions were not documented or attempted prior to or after the use of the Geri-chair with tray table. Record reviews revealed inconsistencies and lack of clarity regarding the use of the restraint. The resident's care plan noted the use of the Geri-chair with or without a tabletop to prevent falls and serve as a table for activities, but did not include interventions for removing the tabletop or assessing the continued need for the restraint. Physician orders and informed consent forms referenced the use of the Geri-chair with or without the tabletop as a safety device, but documentation of less restrictive alternatives and ongoing assessment was incomplete or missing. Physical restraint elimination assessments indicated the resident was a good candidate for restraint elimination, yet the action plan consistently stated no restraint elimination at this time, with minimal documentation of less restrictive measures or specific medical symptoms justifying the restraint. Observations during the survey showed the resident was able to move her upper body and interact with her environment, but was always restrained by the tray table when in the Geri-chair, except for one instance when she was in a wheelchair without a restraint and did not attempt to get up. Staff interviews indicated the restraint was used for fall prevention and at the request of the resident's family, but there was no evidence of regular re-evaluation or consideration of less restrictive alternatives. The facility's restraint policy referenced compliance with laws and professional judgment, but the practice observed did not align with requirements for restraint use only when necessary for medical treatment and with ongoing assessment.
Failure to Refer Resident for PASARR Screening After New Mental Health Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident who was newly diagnosed with a serious mental disorder. Specifically, after a resident was diagnosed with persistent mood disorder and major depressive disorder, the facility did not refer the resident for a Level I PASARR screening as required. The resident's medical record showed multiple psychiatric diagnoses and ongoing treatment with several psychotropic medications, yet no referral was made for further evaluation through the PASARR process. During an interview, the Director of Nursing (DON) acknowledged responsibility for referring residents for Level I PASARR screening if they had a mental illness but stated she did not believe the resident had a psychiatric condition warranting the referral. The DON also indicated she had not consulted with the psychiatric nurse practitioner regarding the resident's condition. Upon reviewing the psychiatric assessment, the DON recognized that the resident could qualify for additional resources and admitted that not referring residents with mental illness for Level I evaluation could result in missed services. Facility policy requires adherence to PASARR guidelines to ensure residents with mental illness receive specialized services.
Failure to Provide Assistance with Personal and Oral Hygiene
Penalty
Summary
A deficiency was identified when a resident with Parkinson's Disease and Dementia, who was bedbound and dependent on staff for all activities of daily living (ADLs), did not receive necessary assistance with personal and oral hygiene. The resident, who primarily spoke Spanish and had moderate cognitive impairment, reported that she was unable to get out of bed and required help with all ADLs. She stated that on the day in question, staff did not assist her with washing her face or brushing her teeth, leaving her feeling dirty and unwell. She also noted that it sometimes took staff an hour or two to respond to her requests for help. Interviews with CNAs revealed that while it was their responsibility to assist residents with morning hygiene tasks such as wiping faces and brushing teeth, these tasks were not completed for this resident on the day observed. One CNA admitted she did not provide care because she was attending to another resident, and acknowledged that not brushing a resident's teeth could lead to infection. The Director of Nursing confirmed that the resident required total care and that CNAs were expected to provide assistance with personal hygiene as part of their duties. Review of facility policy supported that CNAs must attend to residents' needs at all times.
Failure to Maintain Safe and Clean Nebulizer Equipment for Resident Receiving Respiratory Care
Penalty
Summary
A deficiency occurred when a resident requiring respiratory care was not provided with safe and appropriate management of their nebulizer equipment. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and muscular atrophy, was severely cognitively impaired and required assistance with mobility and activities of daily living. Physician orders indicated the resident was to receive DuoNeb treatments every six hours for five days, which was administered as scheduled. However, the resident's care plan did not include any problems or interventions related to nebulizer treatments. During observations, the resident's nebulizer mask was found uncovered, with the elastic band stretched around the nebulizer machine, and a dried white substance present on the mask. The mask and tubing were not dated or covered, and there was no documentation of when they were last changed. Interviews with nursing staff revealed that while masks and tubing were reportedly changed weekly and should be dated and covered, there was no specific documentation to confirm this practice. The Director of Nursing was unaware that the resident was still receiving nebulizer treatments and did not provide a facility policy for respiratory care when requested.
Incomplete and Inaccurate Medical Records in Nutrition Assessment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, the nutrition assessment form for the resident contained the correct name but listed an incorrect admission date, date of birth, height, and ideal body weight range. The dietician, who completed the assessments, acknowledged crossing out and correcting the height and ideal body weight range but was unaware that the admission date and date of birth were incorrect. The dietician also reported experiencing computer issues during this process. Additionally, the resident's care plan and dietary care plan contained handwritten changes and lacked clear dating for some interventions. The resident involved had a history of dementia with behavioral disturbances, diabetes, and vitamin D deficiency, and was noted to have severe cognitive impairment, poor appetite, and significant weight loss. The DON confirmed that having incorrect information in the nutritional assessments could result in not having an accurate weight and dietary assessment for the resident. The facility's medical records policy was requested but not provided by the time of the survey exit.
Failure to Document and Communicate Hospice Services
Penalty
Summary
The facility failed to ensure that hospice services for a newly admitted female resident with diagnoses including anxiety, chronic pain, insomnia, and depression met professional standards and principles. Specifically, the resident's hospice care was not included in her interdisciplinary care plan, and there were no hospice licensed nursing visit notes present in either her hospice binder or medical record. Facility staff nurses were unaware that hospice documentation was required as part of the resident's medical record, and communication between the facility and the hospice provider was limited to verbal reports without proper documentation. Record reviews confirmed the absence of hospice nursing notes in both the hospice binder and the resident's medical record, and interviews with staff revealed a lack of awareness regarding the need for this documentation. The only documentation present in the hospice binder was contact information for the hospice and CNA sign-in sheets, with no licensed nurse visit notes available until after the issue was identified. The DON acknowledged that not having hospice notes in the medical record affected communication regarding the resident's care.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in 16 out of 32 double occupancy rooms. During interviews and record reviews, it was confirmed that these rooms, specifically rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31, did not meet the square footage requirement. The Administrator acknowledged that these rooms were below the required size and stated that a room waiver was in effect, with no changes to the room measurements. Observations of the rooms revealed that the square footage per resident ranged from 61.9 to 79.3 square feet, all below the regulatory minimum for double occupancy rooms. A review of the Resident Room and Bed Report showed that 19 residents were residing in the affected rooms at the time of the survey. No residents were present in some of the rooms during the annual survey.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures designed to prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified through the review of records for two staff members, NA A and NA B, who were not screened through the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) during 2023 to 2024. Despite being employed and working shifts, these staff members had not undergone the required annual background checks to ensure their employability and certification status, as mandated by the facility's policies. The facility's administrator admitted that while original background checks were conducted at the time of hire, the necessary EMR and NAR checks had not been performed annually as required. This oversight was acknowledged despite the administrator's familiarity with the staff and their long-term employment. The facility's policy, which aligns with Chapter 253 of the Health and Safety Code, mandates that all staff must be screened through these registries to prevent the employment of individuals who have committed acts of abuse, neglect, or misconduct. The failure to adhere to these policies could potentially affect all residents by allowing unqualified staff to provide direct care.
Failure to Verify Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that two nurse aides, referred to as NA A and NA B, had completed a nurse aide program and received their certification before allowing them to serve in that capacity. Upon review of their personnel files, there was no documentation confirming that either NA A or NA B had completed the necessary training and certification. Despite this, both individuals were scheduled and worked shifts at the facility, with NA A working from 10:00 PM to 6:00 AM on January 29, 2025, and NA B scheduled for the 2:00 PM to 10:00 PM shift on January 30, 2025. Interviews conducted during the investigation revealed that the facility's administrator (ADM) was aware that both NA A and NA B had not secured their certification. The ADM acknowledged that NA B had completed the course but failed the certification test and expressed no intention to retake it. Despite understanding the state requirement for nurse aides to be certified to ensure they possess the necessary skills for direct resident care, the facility allowed these individuals to work without the proper credentials. This deficiency could potentially affect all residents by having uncertified staff provide direct care.
Failure to Provide Required Abuse and Neglect Training
Penalty
Summary
The facility failed to provide necessary training to their staff on procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. Specifically, two staff members, NA A and NA B, did not complete the required training for the year 2024. This deficiency was identified through a review of employee personnel files and in-service attendance records, which showed that both staff members did not attend the in-service training on abuse, neglect, and exploitation held on October 4, 2024. Additionally, attempts to contact these staff members for further clarification during the investigation were unsuccessful. Interviews with the Director of Nursing (DON) and the Administrator confirmed that NA A and NA B had not completed the necessary abuse training during 2024. The DON acknowledged her responsibility for ensuring all staff are trained on abuse and neglect upon hire and annually. The facility's policy, dated October 2024, outlines the requirement for staff training on abuse prohibition practices, intervention with aggression, and reporting allegations, among other topics. However, the failure to adhere to these training requirements could potentially affect any resident and contribute to incidents of abuse or neglect.
Failure to Maintain Resident Assessments in Active Medical Records
Penalty
Summary
The facility failed to ensure that all resident assessments completed within the previous 15 months were maintained in the residents' active medical records. This deficiency was identified for six residents (Resident #1, Resident #10, Resident #13, Resident #18, Resident #21, and Resident #35) whose MDS assessments were not accessible to staff and ready for review. The MDS assessments were stored in a locked cabinet in the Director of Nursing (DON)/Owner's office, which was only accessible when the DON/Owner was on-site. This practice resulted in the MDS assessments not being available for review when needed, as observed during the state surveyor's review of the residents' charts at the nurses' station, where no MDS assessments were found in any of the six residents' charts reviewed. During interviews, the DON/Owner and the Administrator/Owner acknowledged that the MDS assessments were not kept in the residents' medical records and were instead stored separately in a locked cabinet. The Administrator/Owner explained that a former medical records staff person, who no longer worked for the company, had removed many records from the resident charts, which should not have been removed. The facility's leadership admitted they were unaware that the MDS assessments should be maintained as part of the master record in the residents' active medical records. This oversight affected the facility's ability to provide timely access to essential resident assessments, potentially impacting the quality of care provided to the residents.
Safety and Sanitation Deficiencies in Adjacent Building
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During an observation, it was noted that a building adjacent to the main nursing facility, used for laundry, food storage, and maintenance, had several safety hazards. The dryer electrical cord was wrapped around the flexible gas connection, and the flexible gas tubing connected to the dryer was held in place by a wire tie around a galvanized pipe. Additionally, the maintenance room contained flammable liquids and gases, including gas-powered lawn equipment, premixed fuel, paint thinner, and various flammable aerosol spray cans. Further observations revealed numerous live electrical wires hanging down from the ceiling in the maintenance room, some covered with black tape and others with exposed wiring where the sheath had fallen apart. During an interview, the Administrator acknowledged the use of the building for storage and laundry and mentioned that it had a different address and utility bills from the main building. The Administrator stated that the identified concerns would be corrected immediately.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the resident's status for one resident reviewed for assessments. Specifically, the facility's most recent MDS assessment for a resident included incorrect diagnoses of depression, psychotic disorder, schizophrenia, and post-traumatic stress disorder. These diagnoses were not supported by the resident's medical record or any historical data. The resident's face sheet indicated diagnoses of dementia with behavioral disturbance, hypertension, diabetes with chronic kidney disease, and hyperlipidemia, but not the psychiatric conditions listed in the MDS assessment. During an interview, the DON/Owner admitted to mistakenly checking the boxes for the incorrect diagnoses while completing the MDS assessments. She attributed the error to having completed a large number of MDS assessments at the time. The DON/Owner believed that the mistake did not affect the resident or their care. The facility did not provide a policy related to the completion of MDS assessments when requested prior to the survey exit.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychosocial needs. Specifically, Resident #4 had no care plan in his chart, and Resident #141's care plan was incomplete, containing only two pages. Resident #4, who was severely cognitively impaired with diagnoses including nontraumatic intracerebral hemorrhage, vitamin D deficiency, hyperlipidemia, and age-related nuclear cataract, had no care plan filed in his medical chart. Resident #141, diagnosed with epilepsy, muscle weakness, anxiety, and age-related physical debility, had an incomplete care plan in his medical chart. In an interview, the Director of Nursing (DON) acknowledged that there have been situations leading to missing documents in the charts, including the hiring of someone to thin the charts and requests from the Office of Inspector General (OIG) for documents. The DON also stated that the facility does not have a specific Care Plan policy but follows federal and state regulations. This lack of comprehensive care planning for the residents reviewed indicates a failure to meet regulatory requirements for individualized resident care.
Failure to Provide Minimum Square Footage per Resident
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in 16 of 32 double occupancy resident rooms. Specifically, Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 did not meet the required space per resident. The measurements of these rooms ranged from 61.9 to 79.3 square feet per resident, falling short of the regulatory requirement. This deficiency was confirmed through interviews and record reviews, with the Administrator acknowledging the issue and stating that a room waiver was in effect for these rooms, although the room sizes had not changed. During the survey, it was noted that 19 residents were residing in the non-compliant rooms at the time of the inspection. The Administrator confirmed the room sizes and the existence of a waiver but did not provide evidence that the waiver addressed the current room sizes. The lack of adequate space per resident could potentially impact the residents' activities of daily living, although no specific adverse events were documented in the report.
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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.
Illustrative
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Illustrative
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mccullough Hall Nursing Center Inc | 1.6 mi | — | 0 | 0 |
| Legend Oaks Healthcare And Rehabilitation Center - | 1.9 mi | ★★★★★ | 17 | 0 |
| Windsor Mission Oaks | 2 mi | ★★★★★ | 0 | 0 |
| Avir At San Antonio | 2.4 mi | ★★★★★ | 34 | 1 |
| Hunters Pond Rehabilitation And Healthcare | 3.1 mi | ★★★★★ | 10 | 0 |
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