Health inspection·August 2, 2023

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to follow their policy and procedure (P&P) for pneumococcal vaccination for one of six sampled residents (Resident 1). Resident 1 pneumococcal vaccine (vaccination to protect resident from pneumococcal disease) was not offered and not administered in accordance with the current Center for Disease Control and Prevention (CDC) recommendations. This deficient practice had the potential for acquiring pneumococcal disease for Resident 1. Residents Affected - Few Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 admitted to facility on 5/23/2023 with diagnoses including diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar), sepsis (condition in which the body responds to an infection), and protein calorie malnutrition (deficiency of energy, protein and other nutrients causes measurable adverse effects on body function and clinical outcome). Resident 1 had an assigned resposible party (RP- person acting on behalf of the resident for day-to-day decision making for resident) for decison making. Review of Resident 1's physician orders dated 5/23/2023 indicated Pneumococcal vaccine upon admission and as needed unless it was already been given/or medically contraindicated. Review of Resident 1's minimum data set (MDS, a clinical assessment tool) assessment dated [DATE] indicated Resident 1 was not a candidate for interview with a short term and long-term memory problem. Review of Resident 1's electronic medical record immunization report indicated Resident 1 received pneumococcal conjugate vaccine 13 (PCV 13: type of vaccine used to protect adults against pneumonia) on 5/23/2023. There was no indication that Resident 1 received pneumococcal polysaccharide vaccine 23 (PPSV 23: vaccine protects against 23 types of bacteria that cause pneumococcal disease) 8 weeks after taken PCV 13 as recommended by CDC. Review of CDC pneumococcal vaccine timing for adults 65 years or older indicated For adults with an immunocompromising condition (when people's immune system was not working as well as it should to protect from infection), the minimum interval for PPSV 23 was 8 weeks or more than 8 weeks since last PCV13 dose. Review of CDC pneumococcal vaccination: summary of who and when to vaccinate indicated, increased risk of exposure to pneumococcal infections among people 65 years or older, who are living in nursing homes or other long-term care facilities, and chronic medical condition such as diabetes. (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: 055388 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 055388 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Jose Healthcare & Wellness Center 75 N. 13th Street San Jose, CA 95112 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)