Inspection visit
Inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0557
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to be treated with respect and dignity and to retain and use personal
possessions.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure one of two sampled residents
(Resident 34) received a replacement of her personal belongings when her bilateral (affecting both sides)
hearing aids (small, wearable electronic device to facilitate better communication) were missing since the
end of December 2022. This deficient practice resulted in Resident 34 to be without hearing aids for over
nine months.
Findings:
During a concurrent observation and interview of Resident 34's room on 10/16/23 at 9:55 a.m., Resident 34
stated she was hard-of-hearing and did not have hearing aids on. She stated her hearing aids were with the
medication nurse.
During an interview with certified nursing aide B (CNA B) on 10/18/23 at 9:23 a.m., she stated Resident 34
did not have hearing aids. CNA B stated Resident 34 was hard of hearing and she (CNA B) had to raise her
voice when talking to Resident 34.
During an interview with Licensed Vocational Nurse C (LVN C) on 10/18/23 at 9:47 a.m., she stated
Resident 34 was hard of hearing. She stated Resident 34 used to have hearing aids.
Review of Resident 34's clinical record indicated she was admitted on [DATE] with diagnoses including
unspecified hearing loss, bilateral.
Review of Resident 34's inventory record, dated 9/23/22, indicated she had two hearing aids.
Review of Resident 34's minimum data set (MDS, an assessment tool), dated 9/25/23, indicated the
resident had minimal difficulty (difficulty in some environments e.g., when person speaks softly, or setting is
noisy) in hearing.
Review of Resident 34's Orders - Administration Note, dated 12/24/22, indicated, Hearing aids on both
sides, apply in the morning time . for hearing deficits. Hearing aid not put on. Not in the med cart .
Review of Resident 34's Orders - Administration Note, dated 12/25/22, indicated, Hearing aids on both
sides, apply in the morning time . for hearing deficits. Hearing aid not available .
Review of notes, dated 12/25/22 indicated, Since yesterday, [Resident 34's] hearing aid missing.
(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 9
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
10/20/2023
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)
F 0557
Review of Resident 34's Theft/Loss Report, dated 9/6/23, indicated, missing hearing aid.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 10/18/23 at 3:53 p.m., with Social Services Director (SSD), she stated Resident 34
was hard of hearing. She stated she tried to follow up as soon as she found out Resident 34's hearing aids
were missing but confirmed Resident 34 did not have hearing aids yet.
Residents Affected - Few
Review of the facility's policy and procedure, Theft and Loss, dated July 11, 2017, indicated, When personal
property is reported missing, the staff will immediately begin a search for the missing property. A Theft and
Loss report is to be initiated . The completed Theft and Loss report should be given to Social Services Staff
for further investigation and resolution.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055388
If continuation sheet
Page 2 of 9
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
10/20/2023
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)
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to follow physician's orders when a licensed
vocational nurse (LVN F) did not administer a medication to Resident 152 according to the physician's order
for it. This failure resulted in Resident 152 to not receive the physician's ordered medication as prescribed.
Residents Affected - Few
Findings:
Review of Resident 152's Order Summary Report, dated 10/19/23 indicated the resident was admitted to
the facility on [DATE] with diagnoses including muscle weakness and myocardial infarction (heart attack). It
also indicated Resident 152 had a physician's order, dated 10/5/23, for Polyethylene Glycol 3350 powder
(medication used to manage or treat constipation) Give 17 gram (g, unit of measurement) by mouth two
times a day for constipation prevention.
During an observation and concurrent interview on 10/17/23 at 4:30 p.m., LVN F poured polyethylene glycol
powder into a cap of the container until it filled approximately halfway to the top of a white line. When asked
how much powder was in the cap, LVN F stated it was 17 g. LVN F poured the powder into a drinking cup
and mixed it with water. LVN F administered the polyethylene glycol and other medications to Resident 152.
During an observation and concurrent interview on 10/17/23 at 4:46 p.m., LVN F looked at the polyethylene
glycol container cap and confirmed she did not fill the cap to the indicated line. LVN F stated she should
have filled the powder to the top of the white line.
Review of the directions printed on the polyethylene glycol container, indicated, The bottle top is a
measuring cap marked to contain 17 grams of powder when filled to the indicated line (white section in cap)
. fill to top of white section in cap which is marked to indicate the correct dose (17 g).
Review of the facility's policy, Medication - Administration, revised 1/1/12, indicated, Medications and
treatments will be administered as prescribed to ensure compliance with dose guidelines. The policy also
indicated one of the seven rights of medication is the right amount.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055388
If continuation sheet
Page 3 of 9
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
10/20/2023
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)
F 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure one of two sampled residents
(Resident 34) received assistive devices when when her bilateral (affecting both sides) hearing aids (small,
wearable electronic device to facilitate better communication) were missing since the end of December
2022. This deficient practice resulted in Resident 34 to be without hearing aids for over nine months.
Residents Affected - Few
Findings:
During a concurrent observation and interview of Resident 34's room on 10/16/23 at 9:55 a.m., Resident 34
stated she was hard-of-hearing and did not have hearing aids on. She stated her hearing aids were with the
medication nurse.
During an interview with certified nursing aide B (CNA B) on 10/18/23 at 9:23 a.m., she stated Resident 34
did not have hearing aids. CNA B stated Resident 34 was hard of hearing and she (CNA B) had to raise her
voice when talking to Resident 34.
During an interview with Licensed Vocational Nurse C (LVN C) on 10/18/23 at 9:47 a.m., she stated
Resident 34 was hard of hearing. She stated Resident 34 used to have hearing aids.
Review of Resident 34's clinical record indicated she was admitted on [DATE] with diagnoses including
unspecified hearing loss, bilateral.
Review of Resident 34's inventory record, dated 9/23/22, indicated she had two hearing aids.
Review of Resident 34's minimum data set (MDS, an assessment tool), dated 9/25/23, indicated the
resident had minimal difficulty (difficulty in some environments e.g., when person speaks softly, or setting is
noisy) in hearing.
Review of Resident 34's Orders - Administration Note, dated 12/24/22, indicated, Hearing aids on both
sides, apply in the morning time . for hearing deficits. Hearing aid not put on. Not in the med cart .
Review of notes, dated 12/25/22 indicated, Since yesterday, [Resident 34's] hearing aid missing.
During an interview on 10/18/23 at 3:53 p.m., with Social Services Director (SSD), she stated Resident 34
was hard of hearing. She stated she tried to follow up as soon as she found out Resident 34's hearing aids
were missing but confirmed Resident 34 did not have hearing aids yet.
During a review of the facility's policy and procedure titled, Referral to Outside Services, dated December
01, 2013, indicated, The Director of Social Services coordinates the referral of resident to outside
agencies/programs to fulfill resident needs for services not offered by the Facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055388
If continuation sheet
Page 4 of 9
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
10/20/2023
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)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
Based on observation, interview, and record review, the facility failed to ensure one of three sampled
residents (Resident 16), was provided Restorative Nursing Assistance (RNA; restorative care for individuals
recovering from illnesses or injuries) services as ordered. This failed practice could result in decreases in
mobility and complications for residents requiring RNA services.
Findings:
During an interview with Restorative Nursing Aide A (RNA A) on 10/19/23 at 9:29 a.m., she stated she
works as an RNA 4 days a week on Mondays, Tuesdays, Wednesdays, and Thursdays. She stated there
was currently no other RNA for 27 patients. She stated about once a month for the past 6 months, she was
pulled out of the schedule to work as a CNA (Certified Nursing Assistant, an entry-level role that provides
vital support to both patients and nurses). She stated some residents missed their RNA therapy when she
was pulled out to work as a CNA.
Review of Resident 16's clinical record, on 10/19/2023 at 1:37 p.m., indicated a physician's order, dated
8/17/2023, for RNA services four times a week for three months.
During a concurrent interview and record review of the RNA schedule with RNA A on 10/19/2023 at 2:26
p.m., RNA service logs indicated that Resident 16 received RNA services only twice in one week from
9/24/2023 to 9/30/2023.
During an interview with the Director of Nursing (DON) on 10/19/23 at 3:39 p.m., she stated the facility
needed at least one RNA a day. The DON stated there was only one RNA available four times a week.
Review of facility's policy, titled Restorative Nursing Program Guidelines, dated September 2019, indicated,
The Restorative Nursing program provides nursing interventions that promote the Resident's ability to adapt
and adjust to living as independently and safely as possible.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055388
If continuation sheet
Page 5 of 9
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
10/20/2023
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)
F 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to complete a performance review for one of three
certified nursing assistants (CNA) at least once every 12 months for CNA E. This failure resulted in a lack of
evaluation and feedback related to CNA E's performance.
Residents Affected - Few
Findings:
Review of CNA E's personnel file indicated she was hired on 9/25/12 and had an employee performance
review with competency assessments on 4/23/21.
During concurrent interview and record review on 10/20/23 at 1:28 p.m., the director of staff development
provided competency assessments for CNA E, completed on 8/26/23. The DSD stated it looked like there
was no performance review/competency assessment completed for CNA E in the year 2022.
Review of the facility's policy, revised 3/17/22 indicated, Competency assessments will be performed .
annually . The annual evaluation of an employee will include review of completed competency assessments
which may have been done throughout the year.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055388
If continuation sheet
Page 6 of 9
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
10/20/2023
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on interview and record review, the facility failed to ensure complete records for controlled
medications (those with high potential for abuse and addiction) when controlled medication use audit for
three of six residents (Residents 13, 43, and 153) were not reconciled. The medications were signed out of
the Individual Narcotic Record count sheet (an inventory sheet that keeps record of the usage of controlled
medications); however, they were not documented on the Medication Administration Record (MAR) to
indicate they were given to the residents. This failure had the potential for misuse or diversion (illegal
distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of
controlled medications.
Findings:
On 10/17/23, six random Individual Narcotic Records count sheets for six residents were requested for
review.
Review of Resident 13's clinical record indicated he had a physician's order, dated 6/7/23 for tramadol (a
potent narcotic for pain) 50 mg one tablet every six hours as needed (PRN) for pain.
Review of the count sheet for Resident 13's tramadol indicated the medication was signed out on 10/4/23 at
5 p.m., 10/9/23 at 5 p.m., 10/10/23 at 5 p.m. and 10/10/23 at 11:05 p.m. with no documentation of
administration on Resident 13's MAR.
Review of Resident 43's clinical record indicated he had a physician's order, dated 9/22/23 for
hydrocodone-acetaminophen oral tablet 5-325 mg (a potent narcotic for pain) one tablet every four hours as
needed (PRN) for pain.
Review of the count sheet for Resident 43's hydrocodone-acetaminophen indicated the medication was
signed out on 10/14/23 at 9 a.m. and 10/15/23 at 9 a.m. with no documentation of administration on
Resident 43's MAR.
Review of Resident 153's clinical record indicated he had a physician's order, dated 9/29/23, for
hydrocodone-acetaminophen oral tablet 5-325 mg one tablet every eight hours as needed (PRN) for severe
pain.
Review of the count sheet for Resident 153's hydrocodone-acetaminophen indicated the medication was
signed out on 10/10/23 at 6:30 a.m. and 10/12/23 at 9 a.m. with no documentation of administration on
Resident 153's MAR.
During concurrent record review and interview on 10/19/23 at 1:15 p.m., the director of nursing (DON)
confirmed there was a discrepancy between the count sheets and the MAR for Residents 13, 43, and 153.
The DON stated when a nurse removed a narcotic from the locked narcotic box, signed it out on the count
sheet, and administered the medication, the expectation was it would be documented in the MAR.
Review of the facility's policy, Medication - Administration, revised 1/1/12, indicated, When a PRN
medication is given, it will be charted on the Medication Administration Record. The Nurse will document
the reason given, reason for drug, route of administration, date, and time.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055388
If continuation sheet
Page 7 of 9
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
10/20/2023
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review, the facility failed to ensure food was stored in
accordance to professional standards of food safety when:
Residents Affected - Some
1. Outdated graham cracker crumbs in a plastic container was stored in an active use area of the dry
storage;
2. An ice chest containing ice was stored on the floor.
These failures had the potential to cause foodborne illness for residents who received food from the
kitchen.
Findings:
1. During a concurrent kitchen observation and interview with the Dietary Director (DD) on 10/6/23 at 9:00
a.m., there was a plastic container containing graham cracker crumbs in an active use area of the dry
storage. The container had a label that indicated, 7/17/23, UB [use by]: 9/17/23. The DD confirmed the
graham cracker crumbs had passed its use by date. She stated it should be discarded.
2. During a concurrent observation and interview with the Registered Dietician Nutritionist (RDN) on
10/18/23 at 10:24 a.m., an 85-liter (L, unit of volume) ice chest was on the floor. The RDN confirmed the ice
chest was on the floor and stated ice for residents' consumption was stored inside the ice chest.
During a concurrent interview and record review with the RDN on 10/18/23 at 11:00 a.m., the RDN stated
the ice machine was out of commission since 8/7/23 according to the ice machine log. The RDN stated they
began using the ice chest when the ice machine was out of commission.
Review of the United States Food and Drug Administration's (FDA) 2022 Food Code, indicated, Food shall
be protected from contamination by storing the food . at least 15 cm (6 inches) above the floor .
Review of the facility's policy and procedure titled, Food Storage, dated July 25, 2019, indicated, Food
should be stored off the floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055388
If continuation sheet
Page 8 of 9
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
10/20/2023
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)
F 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
Based on observation, interview, and record review, the facility failed to ensure 10 bedrooms measured at
least 80 square feet per resident. Having less than 80 square feet per resident could potentially
compromise the care and services the residents receive.
Findings:
The residents' bedroom measurements were as follows:
Room Number Bed Capacity Square Feet per Resident
1 2 78
9 3 69
10 3 69
11 2 66
12 3 76
14 3 76
17 3 69
18 3 69
21 3 77
23 3 77
During the survey, residents were observed in their rooms. Nursing care and services were not negatively
impacted by the shortage of space.
During the survey, residents and staff were interviewed to determine if there were any concerns or issues
with the lack of space. The residents and staff verbalized no complaints or concerns regarding space.
Recommend continuance of room waiver.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055388
If continuation sheet
Page 9 of 9
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Back to topCitations
12 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F557 - Respect and Dignity
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- 0041GeneralS&S Epotential for harm
Implement emergency and standby power systems.
- 0211GeneralS&S Dpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the October 20, 2023 survey of SAN JOSE HEALTHCARE & WELLNESS CENTER?
This was a inspection survey of SAN JOSE HEALTHCARE & WELLNESS CENTER on October 20, 2023. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SAN JOSE HEALTHCARE & WELLNESS CENTER on October 20, 2023?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Assist a resident in gaining access to vision and hearing services."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.