Inspection·June 11, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Ombudsman (resident advocate) was notified of discharges for three of three residents (Residents 1, 2, and 3). This failure had the potential to result in the residents not having someone to advocate for their admission, transfer, and discharge rights. Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE]. Review of Resident 1's Progress Notes, dated 4/22/24, indicated the facility informed Resident 1 that her insurance issued a last covered date of 4/25/24 (this indicated the insurance would not pay for Resident 1's stay in the facility after 4/25/24). Review of Resident 1's Progress Notes, dated 4/26/24, indicated Resident 1 was discharged from the facility at 10:50 a.m. There was no documentation in the Progress Notes that indicated the facility notified the Ombudsman of Resident 1's discharge. During an interview with the director of nursing (DON) on 5/31/24 at 12:39 p.m., the DON stated the nurses were responsible for notifying the Ombudsman via fax when residents are discharged or transferred from the facility. When asked how to determine whether or not the information was actually faxed to the Ombudsman, the DON explained that the fax machine would print out a fax confirmation. The DON stated she would try to find documentation that indicated the facility notified the Ombudsman of Resident 1's discharge on [DATE]. During an interview and concurrent record review with the DON on 5/31/24, at 1:27 p.m., the DON presented two documents. One of the documents was Resident 1's Notice of Proposed Transfer and Discharge, dated 4/26/24. The other document was a fax cover sheet, dated 4/26/24 and addressed to the Ombudsman. The subject line on the fax cover sheet was left blank, and there was no documentation that indicated the intended fax was regarding a discharge from the facility. Also, the fax cover sheet did not have a fax confirmation. The DON confirmed there was no indication that the Notice of Proposed Transfer and Discharge was actually faxed to the Ombudsman. On 5/31/24, at 2:30 p.m., the administrator (ADM) presented a different fax cover sheet, dated 4/26/24 and addressed to the Ombudsman. This fax cover sheet did have a fax confirmation printed on the top. However, the subject line on the fax cover sheet was still blank, and there was no documentation that indicated the intended fax was regarding a discharge from the facility. (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 4 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 06/11/2024 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)