Inspection·July 29, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to provide care in accordance with professional standards of practice for two of three sampled residents (Resident 1 and 2) when: Residents Affected - Few 1. Staff did not complete an SBAR (situation, background, assessment, recommendation, a communication tool) and did not notify the physician and the responsible party (RP, person designated to make decisions on behalf of a resident) when an altercation occurred between Resident 1 and Resident 2; 2. Licensed nurse did not do a skin assessment for Resident 1 when Resident 2 threw coffee on Resident 1; 3. Licensed nurses did not put Resident 1 and Resident 2 on alert charting (nurses on each shift closely monitor and document in the medical record for 72 hours about a specific condition) when an altercation between Resident 1 and Resident 2 occurred; 4. Staff did not follow up with Resident 2 following a room change. These failures had the potential to result in inadequate monitoring of the resident's conditions, and the potential to negatively affect the residents' health, safety and well-being. Findings: Review of facility's document titled SOC 341 (Document for reporting suspected dependent Adult/Elder Abuse), dated 1/11/24, indicated at approximately 8:17 a.m., it was reported that Resident 2 threw cold coffee on roommate, Resident 1. A facility's untitled document, dated 1/15/24, contained a summary of the findings regarding the SOC. The summary indicated on 1/11/24 the certified nursing assistant (CNA) noticed that coffee had been spilled on Resident 1. The document further indicated Resident 1 informed the CNA that her roommate Resident 2 had thrown cold coffee on her. Upon interview with Resident 2, Resident 2 admitted to throwing coffee at Resident 1 1. During an interview with the director of nursing (DON) on 7/11/24 at 2:45 p.m., she reviewed the clinical records of Resident 1 and Resident 2 and confirmed there was no SBAR done on 1/11/24 when the incident occurred between Resident 1 and Resident 2. The DON acknowledged an SBAR should have been completed and stated in addition the facility must notify a resident's physician and responsible party if there is an altercation between 2 residents. The DON reviewed Resident 1 and Resident 2's clinical records and confirmed there was no documentation that the physicians and RPs of the residents had been notified. The DON acknowledged the facility should have notified the physicians and the RPs about the altercation between Resident 1 and Resident 2. (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 07/29/2024 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)