Health inspection·April 28, 2025

SAN JOSE HEALTH CARE AND WELLNESS CENTER Exit Date 03/07/2025 The following reflects the findings of the California Department of Public Health during a recertification survey. Event ID: 5E4T11 Facility Reported Incident CA00950309 State Citation B was written REGULATORY VIOLATION(s): F600 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. Title 22 § 72315. Nursing Service - Patient Care (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Title 22 § 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Title 22 § 72527. Patient's Rights (a) Patient have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patient shall have the right: (10) To be free from mental and physical abuse. From 3/3/25 to 3/7/25, an unannounced re-certification survey was conducted at the facility. The facility failed to ensure one (Resident 14) out of 14 sampled residents was free from abuse when staff shouted at and did not acknowledge Resident 14's statement for hunger. This failure had the potential to impact the physical and mental well-being of the resident. A review of Resident 14's clinical record indicated admission date of 6/8/2021 with diagnoses including Unspecified Dementia [decline in mental abilities, like memory, thinking, and reasoning], Type 2 Diabetes Mellitus [a condition where the body either does not make enough insulin or cannot use insulin properly, leading to high blood sugar levels] with diabetic chronic kidney disease [occurs when high blood sugar levels from diabetes damage the kidneys' ability to filter waste and excess fluid], Major Depressive Disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest]. A review of Resident 14's Minimum Data Set (MDS, an assessment tool), dated 2/4/25, indicated a brief interview for mental status score of 12 [BIMS, a tool used to assess cognition (knowing, learning, and understanding), a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. The MDS indicated, Resident 14 had poor appetite or overeating. A review of Resident 14's Psychiatric Evaluation dated 2/28/25 indicated a psychiatric follow up visit dated 12/19/24 indicated, "Symptom #1: mood lability...Symptom triggers: current social, medical condition.... Symptom #2: anxiety... Symptom triggers: current social, medical condition...Associated signs and symptoms: behavioral outbursts, verbal aggression, mood lability, and interpersonal conflicts..." A review of Resident 14's Nutrition/Dietary notes dated 12/2/24 indicated, "significant weight loss of 11.3% within x 180 days..." A review of Resident 14's physician order indicated, "Snacks twice daily at 2 pm and 8 pm two times a day." During an interview on 3/6/25 at 10:58 a.m. with Licensed Vocational Nurse (LVN) G, LVN G stated, Resident 14 eats by herself and was independent. During a kitchen observation and interview on 3/6/25 at 3:10 p.m., a State Surveyor (SS, California Department of Public Health, CDPH nurse surveyor) was walking down the hallway towards the kitchen, this SS observed Resident 14 in a wheelchair, holding the kitchen door slightly opened and was saying "Hello, I'm hungry." The SS heard a shouting voice coming from inside the kitchen said "Go to your room! Go to your room!" Then, a hand was seen trying to close the door and the staff still shouting at Resident 14, "Go to your room!" The SS then showed herself at the kitchen door and witnessed the Dietary Manager (DM) holding the door from inside the kitchen as she was shouting, "Go to your room!" to Resident 14. The DM stopped when she noticed the SS. DM then told Resident 14 that her tray will be brought to her room. Resident 14 let go of the kitchen door and left. The SS entered the kitchen and observed DM was not wearing a hair covering. DM stated she removed it because she was aboutto leave the kitchen. The SS informed DM that emergency food supplies were to be checked, and DM led the SS into the kitchen pantry. The Registered Dietician (RD) came in the middle of checking the emergency supplies. The HFEN asked the DM for appropriate ways on how to address a resident stating hunger, DM did not provide an answer. During an interview on 3/6/25 at 4:12 p.m. with the Regional Registered Dietician (RRD), the RRD was asked what is the appropriate response to a resident who is stating she was hungry, the RRD stated, "We let them know what we can do for them." During an interview on 3/7/25 at 2:04 p.m. with the Dietary Cook (DC), the DC stated, she will not shout at a resident if they were asking for food and instead will say, "How can I help you? What can I do for you?" During an interview on 3/7/25 at 2:22 p.m. with the Director of Nursing (DON), the DON stated, kitchen staff must speak respectfully to the residents. The DON also stated, kitchen staff must let the nurse or nurse aide get the food from the kitchen. A review of facility's Job Description for "Dietary Services Supervisor/Certified Dietary Manager" indicated, "...Ensures that all consumer/resident rights are protected." A facility document entitled, "Employee Relations Conduct" January 2024 edition indicated, "...the following are examples of conduct that are prohibited and will not be tolerated...Rude, discourteous condescending, unprofessional or otherwise socially unacceptable behavior toward a customer, or anyone in contact with the Company...Any employee/resident abuse..." A review of facility's policy and procedure (P&P) entitled, "Resident Rights" revised 1/1/2012, the P&P indicated, "Purpose to promote and protect the rights of all residents at the facility.... Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of residents' rights...III. Each resident is allowed to choose activities, schedules and health care that are consistent with his or her interests, assessments and plans of care, including: A. Sleeping, eating..." This violation occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to a resident.