Inspection·September 13, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received medications as ordered by the physician. This failure had the potential to compromise the resident's health and well-being. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including cellulitis (a type of skin infection) and other disorders of the skin and subcutaneous tissue (the deepest layer of skin). Review of Resident 1's Order Summary Report indicated she had physician orders, dated 8/3/24, for the following medications: 1. Cleocin-T External Lotion (antibiotic lotion used to treat infection) 1% (unit of dose measurement) apply to affected areas topically (to the skin) two times a day for infection; 2. Mupirocin External Ointment (medication used to treat infection) 2% apply to affected area topically three times a day for infected skin; 3. Diclofenac Sodium External Gel (medication used to treat pain) 1% apply to affected area topically four times a day for pain; and 4. Nyamyc External Powder (medication used to treat skin infections caused by fungus) 100,000 units per gram (unit of dose measurement) apply to abdominal fold/groin area topically four times a day for MASD (moisture-associated skin damage). Resident 1's medication administration record (MAR) and treatment administration record (TAR), dated 8/2024, were reviewed. On 8/3/24 and 8/4/24, there were multiple scheduled times for which the above medications were not documented as administered. Instead, the nurses who were supposed to administer the medications documented, 9. Further review of the MAR and TAR indicated a documentation of 9 meant, See Progress Notes. Review of Resident 1's Progress Notes, dated 8/3/24 and 8/4/24, indicated licensed nurse A (LN A) and LN B documented the above medications were on order. During an interview and concurrent record review with LN A on 9/11/24, at 4:11 p.m., LN A reviewed Resident 1's medical record and acknowledged the documentations of 9 and on order regarding the medications mentioned above. LN A stated that on order meant the pharmacy had not yet delivered the medications to the facility. LN A stated she looked for Resident 1's medications but could not find them. During an interview and concurrent record review with LN B on 9/13/24, at 11:09 a.m., LN B reviewed (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 3 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 09/13/2024 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)