F 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and interview, the facility failed to ensure refuse (any disposable materials, which
include recyclable and non-recyclable materials) was disposed of properly when the lid of the garbage
disposal bin in the kitchen was not placed. This failure had the potential to attract insects, rodents, and
other pests to the facility and could affect the 238 residents in the facility.
Residents Affected - Some
Findings:
During an observation on 6/6/24 at 10:55 a.m., three garbage disposal bins were observed in the kitchen.
One garbage disposal bin with a folded box, a cup, two plastic food containers, and a metal food container
on top of the closed bin was observed. One garbage disposal bin without its lid was observed, and refuse in
the garbage disposal bin was exposed to air.
During an observation and concurrent interview on 6/6/24 at 11:13 a.m. with the registered dietitian (RD),
he confirmed the above observation.
During an interview on 6/6/24 at 11:18 a.m. with the RD, he stated that the garbage disposal bin should
have been closed with its lid.
During a review of the facility's policy and procedure (P&P) titled Sanitation and Infection Control dated
2023, the P&P indicated, 2. Kitchen waste that cannot be disposed of by mechanical means will be kept in
a clean, leak proof, nonabsorbent, tightly closed metal or plastic container with a plastic liner.
Review of the Food and Drug Administration's 2022 Food Code 5-501.113, Covering Receptacles,
indicated waste handling for refuse shall be kept covered.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055318
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055318
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Skyline Healthcare Center - San Jose
2065 Forest Avenue
San Jose, CA 95128
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure the environment was free of
pests, as evidenced by multiple flying insects seen in the resident's room and the hallway. This failure had
the potential to cause a health hazard to the 238 residents residing in the facility.
Residents Affected - Some
Findings:
During an interview on 5/1/24 at 1 p.m. with licensed vocational nurse A, she stated there were lots of flies
in Resident 1's room because of old foods in the resident's room.
During a concurrent observation and interview on 5/1/24 with certified nurse assistant B (CNA B),
approximately more than ten black flying insects (fruit flies) were observed in Resident 1's room. CNA B
confirmed the observation.
During an observation on 6/6/24 in Resident 1's room, two fruit flies were observed near bananas on the
over-the-bed table in Resident 1's room.
During a concurrent observation and interview on 6/6/24 with CNA B, Resident 1 was sitting up in his
electric wheelchair in the hallway in front of the nursing station, and one fruit fly was observed near
Resident 1. CNA B confirmed the observation.
During a concurrent interview and the facility's pest control/sightings log on 6/6/24 at 12:55 p.m. with the
maintenance supervisor (MS), he confirmed there was no report of fruit fly in Resident 1's room from 5/1/24
to 6/6/24. The MS stated he did not receive any report of fruit fly in Resident 1's room.
During a review of the facility's undated policy and procedure (P&P) titled Pest Control, the P&P indicated,
Insect or pest sightings are reported to the housekeeping/maintenance supervisor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055318
If continuation sheet
Page 2 of 2
