Inspection visit
Health inspection
10 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 10 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 observation, interview, and record review the facility failed to provide wound treatment as
indicated in the physician's order, and failed to ensure timely follow-up with the wound clinic to clarify what
appropriate treatment would be continued after her appointments were canceled twice for one of two
sampled residents (Resident 29).
Residents Affected - Few
This deficient practice had the potential for Resident 29's heel to worsen.
A review of Resident 29's facesheet indicated diagnoses of non-pressure chronic ulcer (arterial ulcers that
results from an inadequate blood supply due to peripheral vascular disease, diabetes mellitus, trauma, etc.)
on the left foot and congestive heart failure (CHF, a heart condition that causes symptoms of shortness of
breath, weakness, fatigue, and swelling of the legs, ankles, and feet). Her Braden scale (an assessment
tool to predict risk of pressure injury/ulcer) dated 3/13/22 indicated a score of 14 or moderate risk to
develop pressure ulcer/injury (sores (ulcers) that happen on areas of the skin that are under pressure).
A review of Resident 29's Non-pressure ulcer wound on left heel care plan dated 1/9/22 included
interventions to monitor wound daily for change in skin tissue: increase in size, swelling, redness, drainage.
Notify MD as needed, assess wound healing weekly, and treatment as ordered dated 4/22/22.
During an observation on 5/17/22 at 10:54 a.m., Resident 29 was sitting on her wheelchair wearing a
bootee on left foot.
During a record review and interview with the MDSC on 5/17/22 at 3:59 p.m., Resident 29's last wound
clinic visit dated 4/21/22 included a Wound Clinic After Visit Summary that indicated she had wound
debridement (process of removing dead tissue from wounds), return to wound clinic in three weeks. During
this visit, the doctor gave wound instructions to left heel as follows: Do not change dressing this week. In
one week change dressing down to adaptic- leaving in place. Apply a 1 week dressing each week. Remove
dry dressing down to adaptic, rinse vaseline gauze with normal saline, apply 2 x 2 gauze with normal saline
over adaptic, cover with dry dressing. This will be another one week dressing. This treatment order was
transcribed in Resident 29's physician's order dated 4/21/22.
During a concurrent interview with MDSC she stated her wound clinic appointment for 5/12/22 was
canceled, and the next wound clinic appointment was scheduled for 6/2/22. The MDSC also stated
Resident 29 had an infected wound on her left heel and she was seen regularly in a wound care clinic
before the facility had a COVID-19 (Coronavirus disease, an infectious disease, spread from person to
person via respiratory droplets) outbreak.
During the concurrent review with MDSC regarding the wound assessment of the left heel dated
(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 18
Event ID:
555363
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
4/25/22, indicated were measurements of 1 x 2 cm (1 cm. [centimeter, unit of measurement] in length, 2.0
cm. in width and 0 cm. in depth). The wound assessment done 5/14/22 indicated 1.5 x 2.5 x 0 (1.5 cm. in
length, 2.5 cm in width, and 0 cm in depth).
During a wound treatment observation with registered nurse J (RN J) on 5/19/22 at 3:31 p.m., RN J did not
follow the treatment order given by the wound clinic and as indicated in the physician's order dated 4/21/22.
RN J did wound measurement as follows: 4.5 x 3 X 0 (4.5 cm in length, 3.0 cm in width and 0 cm. depth).
During the concurrent record review and interview with RN J, she reviewed Resident 29's physician order
and verified she did not follow the treatment order as prescribed. RN J stated the adaptic dressing was no
longer in place, no vaseline gauze applied. RN J also stated licensed nurses should have followed-up with
the wound clinic to verify regarding any changes in the heel ulcer treatment for any changes in the
treatment since the follow-up appointment was canceled and the current treatment order was no longer
appropriate.
During an interview with the director of nursing (DON) on 5/19/22 at 4:00 p.m., the DON concurred that the
nurse should have called the wound clinic regarding any changes in the treatment order.
A review of the facility's revised April 2018 policy and procedure, Pressure Ulcers/Skin Breakdown -Clinical
Protocol, indicated the physician will order pertinent wound treatments, including wound cleansing and
debridement approaches and application of topical agents. Current approaches should be reviewed for
whether they remain pertinent to the resident's medical conditions, are affected by factors influencing
wound development or healing, and the impact of specific treatment choices made by the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 2 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
During an observation on 5/16/22 at 1:33 p.m., certified nursing assistant H (CNA H) used EZ stand lift to
change Resident 7's incontinent pad by herself.
Residents Affected - Some
During the concurrent interview, CNA H confirmed having used the EZ stand lift by herself and stated if a
resident could stand one staff was enough.
A review of Resident 7's facesheet indicated diagnoses of adjustment disorder with mixed anxiety and
depressed mood, major depessive disorder (a mental health disorder characterized by persistently
depressed mood or loss of interest in activities, causing significant impairment in daily life), hemiplegia
(paralysis of one side of the body)
During a record review on 5/17/22 at 8:13 a.m., the minimum data set coordinator (MDSC) reviewed
Resident 7's minimum data set (MDS, an assessment tool) dated 5/6/22 indicated a brief interview for
mental status (BIMS, an assessment tool for cognition) score of 7 or impaired cognition. The MDSC
confirmed Resident 7 required two staff physical assistance with transfer and toilet use. The MDSC also
reviewed Resident 7's Transfer Program dated on 11/17/21 that indicated CNA should use EZ stand lift with
two persons due to resident's agitation, and resident prefers EZ stand for pericare/toileting.
During the concurrent interview, the MDSC stated Resident 7 could possibly become agitated during care
(transfer and toilet use) which required two staff when using EZ stand lift to ensure the resident's safety.
During an interview and concurrent interview with the director of rehabilitation department (DRD) on
5/18/22 at 1:35 p.m., the DRD stated Resident 7's use of EZ stand lift required two staff because she had
one-sided weakness, and she can't hung on her right side. The DRD confirmed Resident 7's Transfer
Program, completed by rehab depdartment dated on 11/17/21 that indicated CNA should use EZ stand lift
with two persons due to the resident's agitation.
A review of facility's procedure, EZ Lift Stand for Transferring Resident, indicated to use this equipment to
transfer resident for toileting, changing briefs, or moving from bed to chair and back to bed.
A review of the revised July 2017 facility's policy and procedure, Safety and Supervision of Residents,
indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities.
The care team shall target interventions to reduce individual risks related to hazards in the environment,
including adequate supervision and assistive devices.
Review of Resident 28's clinical record indicated diagnosis of dementia (loss of memory, language,
problem-solving and other thinking abilities that are severe enough to interfere with daily life), osteoarthritis
(disease that can affect the many tissues of the joint) of knee.
Review of Resident 28's physician order, dated 4/6/2022, indicated, RNA program to be completed by
CNA's daily ambulation in merry walker 20-30 feet two times/day with supervision as tolerated by patient.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 3 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 2's interdisciplinary screening form indicated, current level: not ambulating in merry
walker. Physical therapist (PT) for ambulation.
During an observation on 5/16/2022 at 9:27 a.m., while in the hallway, Resident 28 was attempting to walk
while using a merry walker. Resident 28 was unsupervised by staff.
Residents Affected - Some
During an interview with the director of rehabilitation (DRD), on 05/18/2022 at 02:08 p.m., DRD stated
Resident 28 uses the merry walker during physical therapy. She further stated Resident 28 should be
supervised by staff when ambulating using a merry walker.
Based on observation, interview and record review, the facility failed to ensure adequate supervision was
provided to three of three sampled residents (Resident 40, Resident 7, and Resident 28) when:
1. Resident 40, who was at risk for falls and injury as indicated in the care plan, was not given staff
supervision with oversight and cues while walking in his room and while in the corridor or hallway;
2. One staff used an EZ stand lift (battery-powered equipment designed to facilitate toileting, changing of
briefs and conducting pivot transfers for weight bearing residents for Resident 7 when two staff were
required; and
3. For Resident 28, facility staff did not provide supervision while using a merry walker (adaptive equipment,
walker/chair combination) in the hallway.
These failures had the potential to result in injury and/or accidents to Resident 40, Resident 7, and
Resident 28.
Findings
1. Record review of Resident 40's face sheet, dated 7/14/2021, indicated Resident 40 had dementia (a
group of conditions resulting in memory loss and impaired judgment), chronic kidney disease (kidney(s)
don't work as they should), and left and right artificial hip joints (removal of hip and replaced with an
artificial joint usually made of metal and plastic).
Record review of Resident 40's Minimum Data Set (MDS, assessment tool used in skilled nursing facilities),
dated 1/19/2022, indicated Resident 40's functional status assessment indicated he needed staff
supervision with oversight and cues while walking in his room and while in the corridor or hallway.
Regarding toilet use, the functional status indicated the resident required limited assistance with at least
one person assisting.
Record review of Resident 40's physician orders, dated 7/15/2021, indicated the resident was a High Fall
Risk and to keep precautions in place.
Record review of a facility incident report, dated 2/13/2022, indicated Resident 40 left the facility in his
wheelchair without staff and without physician or a representative party (RP, person authorized to make
decisions for the resident) authorization, on 2/13/2022 around 10:00 a.m. He went to a church nearby. Per
the report, LVN D was paged overhead by the front desk and told the resident had left the facility in his
wheelchair. She stated she went to the church, found the resident sitting in his wheelchair listening to the
service, and that she then called the facility for activity staff
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 4 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0689
member to supervise Resident 40.
Level of Harm - Minimal harm
or potential for actual harm
During telephone interview with LVN D, on 5/19/2022 at 3:48 p.m., she stated she was notified by page to
come to the front desk, and she did not think it was urgent. She stated she went to the front desk and was
told her resident left. She stated she found him at the back of the church and that she made arrangements
for the activities assistant to stay with him through the church service. She stated she returned to get
Resident 40 at 11:00 a.m. She confirmed he did not have a physician order or RP authorization for him to
be out of the facility. She confirmed he required supervision in the bedroom and the hallway at that time.
Residents Affected - Some
Record review of the the nurse notes by Resident 40's nurse, dated 2/14/2022 at 3:40 p.m., indicated she
found Resident 40 sitting in his wheelchair at the back of the church. She stated .before leaving the church,
I had called for an activity member to supervise the resident.
During interview with the ADM in training, on 5/19/2022 at 1:04 p.m., she stated Resident 40 met the need
for care at the facility and receives Medicare benefits. She stated the physician needs to give authorization
for a resident to leave the facility and confirmed Resident 40 did not have authorization from the physician
or the RP. She confirmed the resident left in his wheelchair and confirmed the activities assistant was not
trained for providing direct care, safety, or supervision.
Review of the facility's job description for the Activities Aide, dated 10/16/21992, indicated the employee
shall have the equivalent of a high school education and assist with activities and events. The job
description indicated no resident supervision responsibilities.
Review of the facility's policy Safety and Supervision of Residents, revised July 2017, indicated the
supervision of the resident is determined by the assessed needs of the resident. The policy further
indicated that resident supervision is a core component of safety.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 5 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
Based on observation, interview, and facility document review, the facility failed to make certain all nursing
staff (licensed nurses and certified nursing assistants) had completed the appropriate competency and skill
check to demonstrate the proper and safe use of EZ stand lift during resident care. Competency and skills
check would ensure staff had demonstrated the correct use of the equipment which would help prevent any
possible accidents and/or injury during care.
During an observation on 5/16/22 at 1:33 p.m., certified nursing assistant H (CNA H) used EZ stand lift (a
battery powered equipment designed to facilitate toileting, changing of briefs and conducting pivot transfers
for weight bearing residents) to change Resident 7's incontinent pad by herself when this resident required
two staff assistance with transfer and toilet use.
A review of the undated facility's lesson plan on Use of the Power Lifts and Scales, utilized to provide
in-service to staff, indicated proficiency of CNAs (certified nursing assistants) included performance
standard that required the student/staff to: Demonstrate Sling Use with the Power Lift and evaluation
required included quiz and return demonstration.
During an interview and record review with the minimum data set coordinator (MDSC) and infection
preventionist (IP) on 5/19/22 at 11:38 a.m., both the IP and MDS stated the nursing staff had watched the
video about the safe transfer but did not conduct an individual staff's skills check of their competence on the
use the EZ stand transfer equipment. The MDSC stated the DSD confirmed there was no competency skills
check completed for any nursing staff on the use of the EZ stand or EZ sling that the facility were using for
resident's transfer and care.
During an interview with licensed vocational nurse D (LVN D) on 5/20/22 at 7:55 a.m., LVN D stated she
worked all shifts. LVN D denied having any in-service and/or competency check done on the use of the EZ
stand lift . LVN D concurred the need to know how to safely use the equipment because she also helped
her nursing assistants during resident transfer and care.
During an interview with CNA A on 5/20/22 at 7:59 a.m., CNA A stated she had an in-service on the use of
EZ lift but denied having done any return demonstration or competency check on the use of the equipment.
During an interview with the administrator (ADM) on 5/19/22 at 9:56 a.m., the ADM stated the director of
staff development (DSD) was on medical leave until June 2022.
During an interview on 5/20/22 at 8:23 a.m., registered nurse C (RN C) stated she needed to learn how to
use the EZ lift and denied having attended the in-service or any competency check on how to safely use
the equipment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 6 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure one of 12 sampled residents (Resident 396) was
free of a significant medication error when Resident 396's Eliquis (a prescription medicine used as a
prophylaxis (preventive treatment) against stroke with atrial fibrillation (AF, an irregular and often very rapid
heart rhythm that can lead to blood clots in the heart) was not administered as ordered by the physician.
This resulted in Resident 396 not receiving 18 doses of Eliquis while in the facility.
Residents Affected - Few
This deficient practice could increase Resident 396's risk of developing a blood clot due to diagnosis of AF
and history of cerebrovascular accident (CVA, the sudden death of some brain cells due to lack of oxygen
when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain).
Findings:
Per review of Resident 396's clinical record, the resident was admitted to the facility on [DATE], with
diagnoses including: hemiplegia following cerebral infarction left nondominant side (paralysis of partial or
total body function on one side of the body), dysphagia following cerebral infarction (difficulty swallowing),
paroxysmal atrial fibrillation, heart failure (occurs when the heart muscle does not pump blood as well as it
should).
Review of Resident 396's physician's order on admission, dated 4/25/2022, indicated Eliquis 2.5 mg tablet,
give 1 tab via GT (gastrostomy tube, a tube inserted through the wall of the abdomen directly into the
stomach) twice daily for Atrial Fibrillation. Indicated on the time administration column to be given at 9:00
a.m., which is once a day only.
Review of Resident 396's medication administration record (MAR, a medical record documenting
administered doses of medication) for April 2022 and May 2022, there was no record indicating the nursing
staff administered the Eliquis twice a day from 4/26/22 until 5/13/22.
During a concurrent record review and interview with the director of nursing (DON) on 5/19/2022 at 11:00
a.m., regarding concern with the missed dose of Eliquis from 4/26/2022 to 5/13/2022. Also informed the
DON that the indicated administration time on the MAR was 9:00 a.m., instead of twice daily which was
indicated on the physician's order. DON stated she was not sure what happened.
During a concurrent interview and record review with registered nurse J on 5/19/2022 at 3:00 p.m., RN J
stated she reviewed the admission physician's order for Resident 396. RN J confirmed that the order for
Eliquis 2.5 mg tablet is to give 1 tablet via GT twice daily for Atrial Fibrillation. RN acknowledged that the
indicated administration time was 9:00 AM, which was only once a day. RN stated that it should have been
9:00 a.m. and 5:00 p.m. RN further stated it should have been caught during the review of the admission
physician's order.
During an interview with the pharmacy consultant on 5/20/2022 at 8:09 a.m., PC stated the manufacturer's
recommendation was twice a day for diagnosis of arial fibrillation. PC further stated not receiving the full
dose increases Resident 396's risk of CVA.
During an interview with Resident 396's primary care physician on 5/20/2022 at 8:28 a.m., she stated she
was not aware about the 18 doses of Eliquis that were missed. PCP further stated Resident 396
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 7 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
would not be at a therapeutic (a drug or treatment for an illness or condition) level having missed that many
doses. PCP stated this would increase the risk of clot formation and puts the resident at a greater risk for
stroke due to diagnosis of atrial fibrillation and history of CVA.
During a follow-up interview with the DON on 5/20/2022, at 11:45 a.m., DON stated nurses should follow
doctor's order and clarify if not clear. DON stated that the admission coordinator (AC) entered the
admission orders, after that the admitting charge nurse would review the orders. DON confirmed that 9 a.m.
was clicked into the MAR but not the evening dose. DON further stated it is a medication error and not
acceptable to have missed 18 doses of medication.
Review of facility's policy, Administering Medications, indicated, Medications are administered in
accordance with prescriber orders including any required time frame .The individual administering the
medication checks the label three times to verify the right resident, right medication, right time and right
method of administration before giving the medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 8 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review, the facility failed to ensure that medications were
stored safely and properly when:
1. One Levemir insulin (long acting insulin) vial for Resident 8 was being used past the discard date;
2. One discontinued Lactulose (laxative for treatment of chronic constipation in adults and geriatric patients)
solution for Resident 39 was still in the medication cart and with no open date;
3. One nursing staff did not count the narcotic (controlled substance) tablets properly during end of shift
narcotic count.
Findings:
1. During a medication cart observation on 5/17/2022 at 3:00 p.m., an opened Levemir 100 unit (u,
standard units of measurement) per milliliter (ml, unit volume for liquids) vial was used past the discard
date. The manufacturer's label indicated, opened date 4/4/2022. Discard date 5/16/2022.
During a concurrent interview with licensed vocational nurse B (LVN B), she confirmed the above
observation. LVN B further stated that the insulin vial should not be used past the discard date.
Review of facility's policy on Administering Medications, dated 4/2019, indicated, The expiration/beyond use
date on the medication label is checked prior to administering.
2. During an medication cart observation on 5/17/2022 at 3:20 p.m., a opened lactulose solution 10g
(grams, a metric unit of mass) per 15ml was found inside the medication cart, with no open date and was
already discontinued.
During a concurrent interview with registered nurse C (RN C), she confirmed that the lactulose solution was
already discontinued and with no open date. RN stated that there should have been an open date. She
further stated that discontinued medications should be removed immediately from the medication cart.
Review of facility's policy Medication Storage, dated 1/2021, indicated, Outdated, contaminated,
discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure
closures are immediately removed from stock, disposed of according to procedures for medication disposal.
3. During a shift change observation on 5/17/2022 at 3:30 p.m., RN C (AM shift) and LVN D (PM shift) were
counting the narcotics. It was observed that LVN D did not count the Norco (narcotic pain medicine) tablets
in the bottle properly. LVN D simply looked quickly inside the bottle of Norco, then proceeded with the
narcotic count.
During a follow-up interview with RN C on 5/19/22 at 10:30 a.m, the state surveyor informed RN C
regarding the above observation. RN C stated that there were 13 tablets of Norco in the bottle. RN
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 9 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0761
stated that the best practice would be to place the tablets on a small tray, then count individually.
Level of Harm - Minimal harm
or potential for actual harm
During an interview with a different licensed nurse, LVN B, on 5/19/2022 at 11:35 a.m., the state surveyor
inquired on their procedure about counting narcotics during change of shift. LVN B took out a small tray
from her medication cart. LVN B stated that when counting narcotics in a bottle, she would place it on a
small tray, and then count it individually.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 10 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0801
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
Based on observations, interviews, and facility document review, the facility failed to ensure the registered
dietitian comprehensively carried out the functions and evaluated the effectiveness of Food and Nutrition
Services when temperatures were not properly monitored for the refrigerator and freezer.
Failure to ensure dietetic services systems are accurately and effectively evaluated may result in the
potential for foodborne illness thus compromising the nutritional status of the residents.
Findings:
Review of facility documents titled Storage Temperature Record Unit 1 Equipment Walk in Refrigerator,
dated April 2022 and May 2022 indicated the acceptable temperature was 41° F (degrees Fahrenheit)
and five out of the 60 temperatures documented were above 41° F (4/29 44° F, 4/30 47° F,
5/2 48° F, 5/14 42° F, 43° F). The Action Taken column was blank for the entire document.
Review of facility documents titled Storage Temperature Record Unit 2 Equipment Walk in Freezer, dated
March 2022, April 2022, and May 2022 indicated the acceptable temperature was 0° F and 152 out of
152 temperatures documented were above 0° F (range from 5-12°F). The Action Taken column
was blank for the entire document.
During an interview on 5/16/22 at 9:35 a.m., DSS A stated the cook checks and records
refrigerator and freezer temperatures every morning and afternoon.
During an interview on 5/17/22 at 9:12 a.m., food service worker G (FSW G) stated she records
temperatures for the refrigerators and freezer in the mornings and is not sure when to report a problem with
freezer temperatures. She thought up to 10°F was acceptable and would not report that to her
supervisor. She further stated she reads the temperature from the temperature indicator on the outside of
the freezer.
During an interview and concurrent record review on 5/18/22 at 12:54 p.m., dietary supervisor F (DS F) in
the presence of registered dietitian (RD) and dietary supervisor E (DS E), while looking at the temperature
logs, verified there were several temperatures above 41°F on the logs for refrigerator 1 and all
temperatures were above 0°F on the logs for freezer 2. He confirmed that staff did not report to him
when the temperatures were out of range, and that they do not have a process to take action if refrigerator
or freezer temperatures are found out of range.
During an interview on 5/17/22 at 3:19 p.m., RD stated she does a monthly kitchen inspection using a form
from her contracted company. She stated she had not reviewed the refrigerator and freezer temperature
monitoring logs as part of this inspection. She stated staff should use the thermometer inside the unit to
record temperatures not the one on the outside of the unit. She further stated temperatures between 6 - 9
°F for the freezer are not acceptable and needed action.
During an interview and concurrent record review on 5/19/22 at 9:15 a.m., the administrator in training
(ADMT), while reviewing facility document titled Quality Assessment for Performance Improvement
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 11 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0801
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
dated 2/22, 3/22, and 4/22 (the monthly kitchen inspections RD performs), confirmed the following were
marked as Met each month: under Refrigerators and Freezers 3. Thermometers are present. Monitored and
recorded properly; 4. Refrigerator temperatures are between 35-40 degrees; 5. Freezer temperatures are at
or below 0 degrees.
During an interview on 5/19/22 at 10:37 a.m., DS F and DS E confirmed there are no records of in-services
for kitchen staff on monitoring refrigerator and freezer temperatures.
Review facility document titled, Orientation, Inservice, and Personnel Management, Department of Food
and Nutrition Services Consultant (Consultant Dietitian) Job Description, dated 2019, indicated under
responsibilities, the RD evaluates and participates in implementing in-service programs for the Department
of Food and Nutrition Services and monitors and recommends food service standards for sanitation, safety,
and infection control.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 12 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on observation, interview, and record review, the facility failed to ensure the planned menu was
followed for six residents (Residents 13, 19, 24, 32, 34, and 38) on pureed diets (texture modified diets for
people with chewing or swallowing difficulties) and two residents (Residents 8 and 36) on controlled
carbohydrate soft diet (CCHO, modified diet for people with diabetes to keep the same amount of
carbohydrates every day).
This failure had the potential to result in not meeting the nutritional needs of the residents.
Findings:
Review of the facility menu Daily Spreadsheet for Monday 5/16/2022 lunch indicated the followings; cilantro
rice puree #8 (1/2 cup) for the Pureed diet and cilantro rice #8 for the CCHO soft diet.
During an observation of the lunch meal service on 5/16/22 at 11:52 a.m. in the kitchen, food service
worker G (FSW G) used # 12 scoop (1/3 cup) to serve the pureed rice and # 16 scoop (1/4 cup) for the
CCHO soft rice.
During an interview and concurrent record review with FSW G on 5/16/22 at 12:01 p.m., she reviewed the
Daily Spreadsheet for Monday 5/16/22 lunch. FSW G confirmed above observation and stated she did not
follow the menu. FSW G acknowledged she should have used # 8 scoop for the pureed rice and the CCHO
soft rice.
During an interview with the registered dietitian (RD) on 5/17/22 at 3:35 p.m., she acknowledged the
planned menu should be followed.
Review of the facility's policy Cycle Menus dated 9/2018, indicated Menus must be followed as written with
exception for when ethnic, cultural, geographic, or religious preferences of the residents require a
substitution.
Review of the facility's policy Trayline setup and service dated 7/2018, indicated Portions are adhered to by
following scoop sizes noted on the menu.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 13 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 and labeled
in accordance with professional standards for food service safety when:
Residents Affected - Some
1. Outdated ground beef was stored in the kitchen refrigerator;
2. Undated shakes were stored in the resident food refrigerator.
This failure had the potential to expose the residents to expired food products.
Findings:
1. During the initial kitchen tour on 5/16/22 at 9:07 a.m., two five-pound packages of ground beef dated
5/12/22 - 5/15/22 were stored in the kitchen walk-in refrigerator.
During an interview with dietary supervisor F (DS F) on 5/16/22 at a.m., he confirmed the two five-pound
packages of ground beef was dated 5/12/22 - 5/15/22.
During an observation on 5/16/22 at 11:20 a.m., DS E took the two five-pound packages of ground beef out
from the kitchen.
During an interview with the registered dietitian (RD) on 5/17/22 at 3:37 p.m., she acknowledged the two
five-pound ground beef dated 5/12/22 to 5/15/22 should have been used by 5/15/22.
During an interview with DS E on 5/19/22 at 9:50 a.m., he stated he took the two five-pound packages of
ground beef dated 5/12/22 - 5/15/22 from the kitchen and threw it away because it was expired.
2. During an observation on 5/16/22 at 3:36 p.m., approximately 32 undated shakes observed in the
resident food refrigerator. Store frozen. Thaw at or below 40 Fahrenheit (F). Use thawed product within 14
days was printed on the shakes carton.
During an interview with licensed vocational nurse B (LVN B) on 5/16/22 at 3:36 p.m., she confirmed the
above observation. LVN B stated she did not know when the shakes came out from the freezer and/or it's
use-by date.
During an interview with the RD on 5/17/22 at 3:38 p.m., she stated shakes should be dated when removed
from the freezer.
Review of the facility's policy Food Storage revised 3/9/2020, indicated Use Use-By dates on all food stored
in refrigerators and use dates according to the timetable in the Dry, Refrigerated and Freezer Storage
Charts. Any expired or outdated food products should be discarded.
Review of the facility's policy Refrigerated Storage Chart revised 12/28/2020, indicated Recommended
storage time at 35-41 F or less: Shakes/Supplements; per manufacturers guidelines, Ground Meat; 1-2
days.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 14 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
3. During the dining observation on 5/17/22 at 12:15 p.m., CNA I did not perform hand hygiene when she
distributed trays and had resident contact to four residents and before assisting Resident 4 with her lunch.
Residents Affected - Some
During the concurrent interview, CNA I validated the observation and stated she was allergic to hand
sanitizer. CNA I stated she should have washed her hands with soap and water due to potential for
contamination.
4. During the dining observation on 5/17/22 at 12:25 p.m., CNA I did not put on the isolation gown before
she entered Resident 4's room to assist her with lunch tray set up, and meals, stayed inside the resident's
room for eight minutes and had her face about one foot away from the resident while she was assisting
Resident 4 with her food.
During the concurrent interview with CNA I, she confirmed she should have put on an isolation gown if she
anticipated to stay long enough to assist Resident 4 with her tray set up and with meals.
During an observation on 5/18/22 at 2:14 p.m., CNA I did not wear her face shield while she was sitting by
the nurses station, and on 5/18/22 at 2:14 p.m., while in the hallway of Station 3.
During the concurrent interview on 5/18/22 at 2:24 p.m., CNA I validated the observation and apologized for
not wearing the correct PPE, and she put on her face shield when her attention was called.
During interview with the Infection Preventionist (IP), on 5/18/2022 at 9:16 a.m., the IP stated that when
staff entered the resident's room and stayed there to assist resident with meals then they should wear the
appropriate PPE that included isolation gown. The IP also stated staff should wash their hands using soap
and water as an option if she was allergic to alcohol. All staff should wear their faceshield while in the
resident care area.
Review of the Centers for Disease Control and Prevention (CDC), reviewed 10/5/2021, indicated the
healthcare staff must wear face shield or goggles, an N95 or higher respirator (face mask designed to filter
small particles of infection), clean gloves, and an isolation gown if closer than six feet to the resident.
Review of the facility's revised 1/2010 policy and procedure on Hand Hygiene Program, indicated that staff
should use appropriate handwashing techniques to prevent the spread of infection. Hand hygiene should be
performed before and wafer entering isolation precautions settings, before and after assisting resident with
meals.
Based on observation, interview, and record review, the facility failed to implement infection control
practices for COVID-19 (cause of global pandemic; highly infectious respiratory virus) on a yellow unit
(unknown COVID-19 status) when:
1. Registered nurse C (RN C) failed to wear required personal protective equipment (PPE, protective
equipment including goggles, face shield, masks, gowns, and are designed to protect the wearer from
infection) face shield or goggles while in close contact with Resident 12;
2. Certified nursing assistant A (CNA A) failed to wear required PPE while providing direct
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 15 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0880
resident care to Resident 35.
Level of Harm - Minimal harm
or potential for actual harm
3. CNA I did not perform hand hygine in between resident contact while distributing meal trays to four
residents and before assisting Resident 4 with her meals.
Residents Affected - Some
4. CNA I did not wear an isolation gown while providing direct resident care to Resident 4 and CNA I did not
wear face shield while in the resident care area.
These deficient practices had the potential to result in a cross-contamination and the spread of infection for
all 48 residents.
Findings
1. During observation, on 5/16/2022 at 9:46 a.m., RN C, entered Resident 12's room without wearing an
isolation gown or gloves. She was less than one foot from Resident 12 and was leaning over and talking to
the resident.
During interview with RN C, on 5/16/2022 at 9:51 a.m., she stated the resident was hard of hearing. RN C
confirmed she should have on a gown and gloves because she was closer than six feet from the resident.
During interview with the Infection Preventionist (IP), on 5/18/2022 at 9:16 a.m., the IP stated that staff in
the resident's rooms should wear an isolation gown and gloves if the resident is less than 6 feet away.
Review of the Centers for Disease Control and Prevention (CDC), reviewed 10/5/2021, indicated the
healthcare staff must wear face shield or goggles, an N95 or higher respirator (face mask designed to filter
small particles of infection), clean gloves, and an isolation gown if closer than six feet to the resident.
2. During observation of CNA A, on 5/18/2022 at 9:03 a.m., CNA A was providing direct care to Resident
35 and did not have on protective eye wear (goggles or face shield).
During interview with CNA A, on 5/18/2022 at 9:10 a.m., she apologized and stated she should have on a
face shield or goggles when providing care to prevent the spread of COVID-19.
During interview with the Infection Preventionist (IP), on 5/18/2022 at 9:16 a.m., the IP stated that staff
should wear face shield or goggles when in the rsident's rooms to prevent the spread of COVID-19.
Review of the Centersfor Disease Control and Prevention (CDC), reviewed 10/5/2021, indicated before
caring for a resident with COVID-19 or a resident with unknown or suspected COVID-19 infection, the
healthcare staff must wear face shield or goggles, an N95 or higher respirator (face mask designed to filter
small particles of infection), clean gloves, and an isolation gown.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 16 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation interview, and record review, the facility failed to provide a safe and comfortable
environment;
Residents Affected - Few
1. Alcohol beverages for a resident was stored open to the resident's hallway in unlocked pantry, without
any inventory system for the alcohol, and without any tracking for the resident;
2. An accessible blanket heater in operation was stored open to the resident's hallway in an unlocked linen
closet;
This had the potential to adversely affect the health and safety of those 48 residents and any visitors in the
facility.
Findings:
During observation, on 5/19/2022 at 9:49 a.m., three residents were walking in the hallway which
connected both resident hallways. During this observation, two more residents were outside the resident
pantry in wheelchairs.
1. Record Review of Resident 21's physician orders, dated 4/30/2021, indicated Resident 21 may have an
occasional alcoholic beverage such as beer or red wine.
During interview with the director of nursing (DON), on 5/17/2022 at 1:20 p.m., indicated that in order to
have alcohol, a resident must have a physician order for it. She stated the resident would need a provider
order indicating how much alcohol can be permitted per day. The DON confirmed there was no log
accounting system for the alcohol and no monitoring system for how many beer given per day. The DON
confirmed there were no parameters on how much beer could be consumed by the resident. The DON
confirmed there was no care plan for alcohol.
During observation and concurrent interview with licensed vocational nurse B (LVN B), on 5/17/2022 at
12:16 p.m., the closet door to the resident pantry was open to the resident hall on Cherry Lane. LVN B
confirmed this observation and stated it should have locked door. She stated the door does not lock when it
is shut. LVN B confirmed the observation that resident food items are stored in the pantry refrigerator. LVN
B confirmed the observation that 10 unopened glass beer bottles with 5% alcohol were in the refrigerator.
She confirmed the alcohol was for Resident 21.
During interview with the dietary supervisor (DS), on 5/19/2022 at 10:12 a.m., he stated any alcohol should
be locked in the medication room and stated it always needs to be locked. He stated anyone in the resident
the hall would have access to the alcohol and confirmed it is a safety issue for residents and for any
visitors.
During interview with the director of nursing (DON), on 5/17/2022 at 1:20 p.m., she confirmed the door to
the pantry does not have a lock, was on a resident hall, and that anyone could access the pantry from the
resident hall. The DON confirmed that once inside the pantry the beer can be accessed by opening the
refrigerator.
During a phone interview with the medical doctor (MD), on 5/19/2022 at 1:39 p.m., he stated the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 17 of 18
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
555363
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Glen Skilled Nursing
2671 Plummer Avenue
San Jose, CA 95125
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 0921
Level of Harm - Minimal harm
or potential for actual harm
facility should be tracking how many or how much alcohol was at the facility and the facility should be
tracking how many Resident 21 consumes. He confirmed a provider can authorize alcohol for the resident.
He stated that the storage should have been locked and not in a public location with by other residents and
the general public. MD confirmed it was a safety concern to have in an unlocked pantry on a resident
hallway.
Residents Affected - Few
Record Review of the facility's policy Hazardous Areas, Devices and Equipment, revised 7/2017, indicated
that the facility identified anything with what the potential to cause injury, and that is accessible to a
vulnerable resident is to be considered a hazard and unsafe with the potential to cause injury or illness.
2. During observation on the resident's hall, on 5/16/2022 at 9:43 a.m., the door to the linen closet was
open to the resident hallway and in the closet on the right was a turned on blanket heater.
During observation and concurrent interview with the housekeeping assistant A (HA A), on 5/16/2022 at
9:43 a.m., she confirmed the observation that the linen closet was open to the resident hallway and that a
blanket warmer/heater was turned on inside of it.
During interview with the HA A, on 5/16/2022 at 9:43 a.m., she confirmed the linen closet did not have a
lock. She confirmed the blanket warmer can be opened by the door and stated it did not have a lock. She
stated the door to the linen closet should be shut and confirmed that anyone in the resident hall could
access the linen closet and the blanket heater by opening the door to the closet.
During interview with registered nurse C (RN C), on 5/16/2022 9:50 a.m., she confirmed the linen closet
door was open to the resident hallway, confirmed it did not have a lock, confirmed that it had a blanket
heater in the closet, and confirmed that anyone could access the closet by opening the door.
During observation and concurrent interview with the Infection Preventionist (IP), on 5/17/2022 at 8:08 a.m.,
the IP confirmed the linen closet door was open to the resident hallway and it should have locked the door.
She stated it should be always locked.
During interview with housekeeping supervisor (HS), on 5/16/2022 at 11:19 a.m., she confirmed that
residents and visitors can access the linen closet and stated .it is a safety issue now that you mention it. I
did not think of it. Maybe maintenance can make a new key. The blanket heater goes up to 160 or degrees.
It does make sense to lock it for resident safety.
Record Review of the facility's policy Hazardous Areas, Devices and Equipment, revised 7/2017, indicated
that the facility identified exposure to a heating element to be a hazard and unsafe with the potential to
cause injury or illness.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555363
If continuation sheet
Page 18 of 18
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Back to topCitations
10 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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the May 20, 2022 survey of LINCOLN GLEN SKILLED NURSING?
This was a inspection survey of LINCOLN GLEN SKILLED NURSING on May 20, 2022. The surveyor cited 10 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LINCOLN GLEN SKILLED NURSING on May 20, 2022?
Yes, 10 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
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.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.