San Jose Nursing Center

In the surveyor’s words

From the most serious findings on record at San Jose Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 28, 2021

  Based on observation, interview, and record review the facility failed to ensure the resident's right to be free from abuse for 1 of 7 residents (Resident #1) reviewed for abuse in that: CNA A placed Resident #1 in the shower while clothed, intentionally wet her clothes to encourage her to remove them, and Resident #1 was made to shower against her will. The DON developed/wrote a policy directing staff to wet residents clothings when they refuse to bathe to get them to shower. Resident #1's comfort items (baby dolls) were taken away from her against her will and over her stated objection. This failure resulted in identification of an Immediate Jeopardy (IJ) on 09/23/2021 at 5:12 p.m. […]

• Immediate jeopardy, isolatedF835Sep 28, 2021

  Based on observation, interview, and record review, Administration failed to administer resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for administration in that: The DON confirmed she wrote the policy and had instructed the CNAs to wet residents clothing with water if they refused to shower. The Administrator should have been aware of the policy which constituted the abuse Resident #1 endured as a result of the DON's instruction. The Administrator failed to adequately supervise the DON and nursing staff to ensure residents were free from abuse. This failure resulted in identification of an Immediate Jeopardy (IJ) on 09/23/2021 at 5:12 p.m. […]

• No harm, potential for more than minimal, patternF656Jun 26, 2026

  Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 12 residents (Resident #1, #19, #21, and #25) reviewed for care plans:1. The facility failed to ensure Resident #1's care plan reflected the resident was at risk for pressure ulcers and used heel protectors.2. The facility failed to ensure Resident #19's care plan reflected the resident was treated with antipsychotic medications.3. […]

• No harm, potential for more than minimal, patternF755Jun 26, 2026

  Based on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 3 carts (west ramp medication aide cart) reviewed for pharmacy services. The facility failed to ensure the controlled substance reconciliation log was signed for accuracy of medication quantities during shift change. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life.The findings included: During an observation of the west ramp medication aide cart on 6/26/2026 at 9:00 AM, the controlled medication reconciliation log revealed 17 signatures were missing from the log between… […]

• No harm, potential for more than minimal, patternF812Jun 26, 2026

  Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 Kitchen reviewed for food safety requirements.1. The facility failed to label and date half a tomato wrapped in clear wrap in the reach in refrigerator; the Dietary Supervisor's hair was not completely covered by a hair restraint, and the facility failed to provide a readily accessible hands-free covered trash receptacle in the kitchen. Kitchen staff were required to touch the trash can lid to dispose of waste.2. […]