Milpitas Care Center

In the surveyor’s words

From the most serious findings on record at Milpitas Care Center, in the surveyor’s own words.

• Actual harm, isolatedF692Jun 27, 2025

  Based on observation, interview, and facility document review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of 18 sampled residents (Resident 12) when Resident 12 experienced an unplanned insidious weight loss of 10 pounds, 6.8% in three months and 16 pounds 9.8% weight loss in six months. This had the potential to result in muscle wasting, loss of independence, decreased quality of life, and increased disease complications. […]

• Actual harm, isolatedF689Mar 10, 2022

  Based on interview and record review, the facility failed to provide adequate supervision to prevent one of two residents (Resident 1) from leaving the facility without staff's knowledge and permission when staff did not follow the plan of care to provide a wander alert (such as WanderGuard, a device applied to the resident's body designed to support caregivers, with simple keypad commands, the option for door bypass using keypads that helps prevent elopement), and to monitor Resident 1's location every 60 minutes. […]

• No harm, potential for more than minimal, widespreadF812Jun 27, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. While feeding the two residents (Residents 25 and 3) certified nursing assistant (CNA) E touched the resident cups without conducting hand hygiene between helping the residents; 2. While assisting a resident (Resident 25) with feeding, CNA E handled the drinking surface of resident's cup; 3. The dry food storage shelves were in poor condition; and 4. […]

• No harm, potential for more than minimal, widespreadF880Jan 4, 2023

  Based on observation, interview and record review, the facility failed to implement infection control measures when: 1. One licensed nurse was assigned to the facility ' s red zone (COVID unit - dedicated area for residents with Coronavirus infection [COVID-19, a disease caused by a contagious virus]) and to green zone (dedicated area for residents negative for the virus) 2. The certified nursing assistant A (CNA A) assigned to the red zone was found at the green zone nurse station. 3. The housekeeper (HK) did not perform hand hygiene after cleaning room AA, before entering room BB, before donning (putting on) gloves and after leaving room BB. These failures had the potential to result in transmission and spread of infection throughout the facility. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF812Jul 22, 2022

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food safety when: 1. Time Temperature Control for Safety Foods (TCS=food requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or [CONDITION(S)] organisms capable of causing a disease or toxin formation) were above 41°F (°F, a temperature scale) in the Residents' refrigerator, and refrigerator and freezer temperatures were not monitored, 2. Residents' food items were not monitored for expiration dates, 3. Staff did not perform proper hand hygiene while dishwashing, 4. A can opener was not kept in sanitary condition, 5. […]