Health inspection·July 26, 2024

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary behavioral health service to maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment to two of three sampled residents (1 and 2) when their psychiatric services were not being followed up. This failure had a potential to affect maintaining Resident 1 and 2's highest practicable mental and psychosocial well-being. Findings: Review of Resident 1's face sheet indicated she admitted to the facility on [DATE] and her diagnoses including Obsessive -compulsive personality disorder (is a mental health condition that cause an extensive preoccupation with perfectionism, organization and control), bipolar disorder(is a mental health condition that affects your moods, which can swing from 1 extreme to another) and major depressive disorder(is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Review of Resident 1's Psychiatric Visit Progress Report dated 6/22/23, indicated psychiatrist evaluated and reviewed Resident 1's medications and management with stating a follow-up should be done within two to four weeks or as needed (PRN) while in the facility. Further review indicated no follow-up psychiatric services were provided. Review of Resident 2's face sheet indicated he readmitted to the facility on [DATE] and his diagnoses including dementia (is a term used to describe a group of symptoms affecting memory, thinking and social abilities). Review of Resident 2's care plan, dated 11/21/23, indicated he had a plan of care to address not sleeping at night. Review of Resident 2's Psychiatric Visit Progress Report dated 4/7/22, indicated it was an initial eval for Resident 2 and would need to have follow-up within two to four weeks or as needed (PRN) while in the facility. Further review indicated no follow-up psychiatric services were provided. During an interview and record review on 7/9/24, at 11:30 a.m., with the social service assistant (SSA), she reviewed Resident 1 and 2's clinical records with stating that Resident 1 and 2 should have followed up with psychiatric services as per their planning of psychiatric visit progress report. During an interview on 7/9/24, at 12:30 p.m., with the assistant director of nursing (ADON), she (continued on next page) 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 07/26/2024 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)