Health inspection·June 25, 2024

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 follow their plan of correction from 2024's recertification survey to have immediate pest treatment to maintain an effective pest control program for ensuring facility is free of pests and rodents when pest sightings were identified, and cockroaches were seen ongoing by staff and residents in the facility. This failure affected residents' quality of life to live in a health and sanitary environment. Residents Affected - Few Findings: Review of complaint intake with received date 05/29/2024 21:57, indicated complainant complained about the facility for being very dirty; cockroaches could be seen on the walls and floors in majority of residents' room and some of residents' rooms in station three broke infection guidelines. Review of the facility's plan of correction, dated 3/1/24, indicated the last survey with exit date was 1/31/24 and the plan of correction included sighting rounds and calling pest control vendor for immediate treatment when pest sightings identified. Review of the facility's pest control service record from 2/2024 to 5/2024 indicated facility received weekly pest treatment. There were no extra records for receiving immediate treatment after cockroaches were found. During a review of facility's pest control binder for all nurses' stations, kitchen, housekeeping and maintenance areas, laundry area and rehabilitation department from 1/31/2024 to 6/1/2024 indicated, on different dates and time cockroaches had been identified on 1/31/24, 2/2024, 3/2024, 4/2024, 5/2024 and 6/1/24 and documented on the pest control log for residents' room in the nursing stations one to six, kitchen and activity room including storage room and office. During an interview on 6/4/24, at 11 a.m., with the licensed vocational nurse A (LVN A), in the nursing station three, she stated that about 2-3 months ago she had seen cockroaches in the nursing station. During environmental observations and interviews on 6/4/24 , at around 12:00 p.m., with the housekeeping supervisor (HS) in room G, we met one of two sampled residents (1) in the room, the resident stated that he just saw cockroaches yesterday in his room. At 12:14 p.m., in room I, a case of bottled water placed on the floor of bed two with lots of personal stuff placed on the floor blocking screen door pathway. At 12:16 p.m., in Room J, trash residuals and paper tissue were found on the floor. At 12:17 p.m., unclean floor was observed in resident's room L. At 12:18 p.m., a live cockroach was found in the shared restroom between room K and L. HS immediately killed the cockroach and used a paper towel to clean the floor and wrapped it around throwing into the garbage can. At 12:20 p.m., we Page 1 of 2 055318 055318 06/25/2024 Skyline Healthcare Center - San Jose 2065 Forest Avenue San Jose, CA 95128

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few walked into room H and met with one of two sampled residents (2) who sat in the wheelchair, he stated that he saw ants in his bed and had seen cockroaches in the past. Some food residuals were found left on the floor on his bedside. At 12:30 p.m. to 12:31 p.m., observed unclean floor in rooms M and N. During an interview on 6/4/24, at 12:33 p.m., with the registered nurse B (RN B) and HS, in nursing station one, she stated that once in a while she would see cockroaches in the resident's room and required documenting on the pest control log which is available in each nursing station, kitchen, activity area HS confirmed after cockroaches are identified, it would be killed immediately and cleaned up, then pest control vendor would come weekly to provide pest treatment. During a kitchen observation and interview on 6/4/24, at 12:45 p.m., with the dietary manager (DM), staff was in the process with tray line and an overflow water was found under the dishwasher. DM stated the maintenance was notified and would fix the problem. DM further stated that yesterday he just saw a dead cockroach in the kitchen office, it was documented on the kitchen pest control binder after each time he saw cockroaches and pest control vendor would come weekly to provide pest treatment. During an interview on 6/4/24 , at 1:20 p.m., with the administrator (ADM), he stated, cockroaches was ongoing project and should have at least one year to solve the pest issue especially for German cockroaches. During an observation and interview on 6/4/24, at 3:36 p.m., with the certified nursing assistant C (CNA C) in room G, observed trash residuals on the floor between bed one and two. CNA C validated the findings. During an observation and interview on 6/4/24, at 3:40 p.m., the floor of small multipurpose activity-dining room in front of room E and F had lots of food residuals on the floor. CNA D validated the findings. During a telephone interview on 6/17/24, at 10:58 a.m., with HS, she stated after each time cockroaches are identified in the different areas of the facility, they would need to kill it and used environmental protection agency (EPA, is responsible for the protection of human health and the environment) registered disinfectants for localized cleaning and followed up with deep cleaning at the area where the cockroaches were found. Additionally, the cockroaches' findings would be discussed during daily conference meeting and then followed up with pest control vendor for immediate treatment after pest sightings were identified. Review of the facility's undated policy and procedure (P&P) titled, Pest Control, indicated Routine inspections are conducted at the Company for evidence of pests. Report the following insect or pest related information: type of problem, location, person reporting, and time reported. Contact with a licensed pest control vendor Keep facility grounds free of trash and brush. 055318 Page 2 of 2