Santa Clara Post Acute

In the surveyor’s words

From the most serious findings on record at Santa Clara Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 29, 2023

  Based an interview and record review the facility failed to provide required assistance while eating for one out of four sampled residents (Resident 1). Resident 1's minimum data assessment (MDS: Clinical and functional assessment tool) dated [DATE] indicated, Resident 1 required extensive assist (extensive assistance: resident involved in part of the activity and staff provided full assistance with no participation by resident three or more times over the 7 days period) with 1 staff physical assist with his eating. […]

• Actual harm, isolatedF689Nov 29, 2022

  Based on interview and record review the facility failed to: 1. Ensure safety for Resident 1 when Resident 1's physician ordered diet was not followed; 2. Ensure that Resident 1's dietary profile was followed, which required staff supervision while eating; 3. Follow the facility's policy and procedure on Nutrition Management of Dysphagia Mechanical, dated 2020, when CNA C provided a peanut butter and jelly sandwich to Resident 1 which resulted in Resident 1 choking and being transferred to the general acute care hospital (GACH) for urgent treatment. As a result of these failures, Resident 1 was sent to the GACH on [DATE] to have a large food bolus removed via laryngoscopy (a procedure where a tube placed in the throat and allows doctors to remove foreign objects). […]

• Actual harm, isolatedF607May 3, 2022

  Based on interview and record review the facility failed to implement written facility abuse policy and procedures to prevent abuse for three of three sampled residents (Resident 32, Resident 100, and Resident 119) when the facility failed to: 1. Report Resident 32's and Resident 100's allegation of abuse regarding humiliation. The facility failed to suspend the accused admissions coordinator (AC) when the facility became aware of the allegation of abuse, did not investigate the allegation of abuse and complete a written report of the investigation's findings within five working days of the occurrence, or complete a background check on the AC prior to employment with the facility; 2. […]

• No harm, potential for more than minimal, widespreadF802Sep 12, 2025

  Based on observation, interview, and record review, the facility failed to ensure staff for the food and nutrition services department competently carried out kitchen duties in a safe, and sanitary manner when a staff member was unable to verbalize and demonstrate correct techniques related to testing the sanitizer buckets. This practice had the potential for 172 residents who received food from the kitchen to be exposed to food borne illness due to lack of staff training and monitoring of their duties. Findings:On 9/10/25 at 8:59 a.m., an observation and interview was conducted with Dietary Aide (DA) F. DA F demonstrated the testing of a sanitizing solution, which was contained inside a red bucket. DA F dipped the test strip in the solution for approximately 1-2 seconds. […]

• No harm, potential for more than minimal, widespreadF802May 10, 2024

  Based on observation, interview and record review, the facility failed to ensure, staff performed their job functions competently according to standards of practice when one cook did not properly verbalize the cool down process for cooking any hot foods such as meat dishes. This failure had the potential to expose 175 residents to food borne illnesses. Findings: During an observation on 5/7/24 at 9:39 a.m., Cook J was seen attending to pots and pans on the stove. During an interview on 5/7/24 at 9:39 a.m., Cook J was asked about the proper coo ldown process for cooked foods such as meat dishes. Cook J stated, the food was cooked to 165 degrees Fahrenheit (F, scale for measuring temperature), then cooled down to 145 degrees F in one hour. […]