Inspection visit

InspectionMarch 1, 2024

MILPITAS CARE CENTERCMS #55575725 citations on this visit

25 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 25 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview and record review, the facility failed to ensure respect and dignity for two of 12 sampled residents (Resident 17 & Resident 19) during mealtime. These failures had the potential to negatively affect Resident 17 & Resident 19's emotional health. Findings: During an observation on 2/26/24, at 12:00 p.m., Certified Nursing Assistant (CNA) D assisted Resident 17 while eating lunch. CNA E was standing over Resident 17, who was sitting in bed in an upright position. During an observation on 2/26/24, at 12:00 p.m., CNA C assisted Resident 19 while eating lunch. CNA C was standing over Resident 19 and Resident 19 who was sitting on bed in an upright position. During an interview on 2/26/24, at 12:11 p.m., with CNA D, CNA D stated, she assisted Resident 17 while eating lunch. CNA D stated she was standing and she was supposed to sit down while assisting Resident 17. During an interview on 2/26/24, at 12:15 p.m., with CNA C, CNA C stated she assisted Resident 19 while eating lunch and she was standing over him. CNA C stated she was supposed to sit down while assisting Resident 19. During a review of the facilities policy and procedure (P&P) titled, Dignity, dated (2021), the P&P indicated, 5. When assisting with care, residents are supported in exercising their rights. For example, residents are: . e. provided with a dignified dining experience. 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 13 Event ID: 555757 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. 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 provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a financial liability notice) for one of three sampled residents (Resident 27). Residents Affected - Few This failure could lead the resident unknowingly assume financial liability for receiving services that were not covered by Medicare (federal health insurance for anyone age [AGE] and older, and some people under 65 with certain disabilities) . Findings: During a review of Resident 27's face sheet (a document that contains a summary of a resident's personal and demographic information), it was indicated Resident 27 was admitted to the facility on [DATE] and her stay was paid by Medicare until 9/29/23. Resident 27 was currently resided at the facility. During a concurrent interview and record review on 2/28/24 at 11:51 a.m. with the Social Services (SS), Resident 27's Notice of Medicare Non-Coverage (NOMNC, a notice that indicates when a resident's stay at a SNF is no longer covered by Medicare) was reviewed, the NOMNC indicated Resident 27's Medicare last cover date was 9/29/23. The SS stated the facility did not issue a SNF ABN when Resident 27's Medicare was terminated, the resident and her daughter were only provided SNF ABN upon admission on [DATE]. During a review of the facility's policy and procedure (P&P) titled Medicare Advance Beneficiary and Medicare Non-Coverage Notices, revised September 2022. The P&P indicated, 2. The facility issues the Skilled Nursing Facility Advance Beneficiary Notice (CMS form 10055) for the following triggering events: [ .] c. Termination - In the situation in which the facility proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF ABN is issued to the beneficiary before such extended care items or services are terminated. 3. The resident (or representative) informed that they may choose to continue receiving the skilled services that may not be paid for by Medicare, and assume financial responsibility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 2 of 13 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) with the resident, or resident representative, document the use of alternatives prior to installation of bed rails for three of 23 residents (Resident 23, Resident 25, and Resident 131), and obtain informed consent prior to the use of bed rails for three of 23 residents (Resident 4, Resident 6, and Resident 18). These failures had the potential to put the residents at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails. Findings: During an observation on 02/26/24, at 09:05 a.m., Residents 4, 6, 18, 23, 25, and 131 had side rails up and installed on their beds. During an interview on 2/27/24, at 1:45 p.m., with Certified Nursing Assistant (CNA) C, CNA C stated, Residents 4, 6, 18, 23, 25, and 131 have side rails up on their beds. During a record review of Residents 4, 6, and 18's Medical Records (undated), it was indicated there was no signed informed consent for the use of bed rails. During a record review of Resident 23, 25 and 131's Medical Records (undated), it was indicated there was no documentation of the use of alternatives prior to installing bed rails, and no documentation of the resident risk assessment for bed rails. During an interview on 3/1/24, at 10 a.m., with Director of Nursing (DON), the DON stated there was no documentation of Resident 23, Resident 25, and Resident 131' regarding the use of alternatives prior to installing bed rails. DON stated, there was no documentation of Resident 4, Resident 6, and Resident 18's informed consent for the use of side rails. During a review of the facility's Policy and Procedure (P&P) titled, Bed Safety and Bed Rails, dated 2022, the P&P indicated, 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) was prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 3 of 13 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed complete annual performance reviews for 2 of 4 sampled staff (Certified Nursing Assistant [CNA] E and CNA C). These failures had the potential to negatively affect patient care. Residents Affected - Few Findings: During a review of CNA E's employee record (undated), the employee record indicated, CNA E was hired on 11/8/22. During a review of CNA C's employee record (undated), the employee record indicated, CNA C was hired on 2/6/23. During a concurrent interview and record review on 2/28/24, at 1:48 p.m., with Director of Staff Development (DSD), CNA E's employee record was reviewed. The employee record indicated, no performance reviews since start date. DSD stated, CNA E had no performance review since she started working in 2022. CNAs are supposed to have a performance review annually. During a concurrent interview and record review on 2/28/24, at 1:50 p.m., with DSD, CNA C's employee record was reviewed. The employee record indicated, no performance reviews since start date. DSD stated, CNA C had no performance review for February 2024. During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations dated 2020, indicated, The job performance of each employee shall be reviewed and evaluated at least annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 4 of 13 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 - Few 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 store temperature sensitive medications appropriately. This failure had the potential for residents to receive medications with limited effectiveness. Findings: During a concurrent observation and interview on 2/26/24, at 11:47 a.m., with Licensed Vocational Nurse (LVN) F, in Medication Storage Room, the medication refrigerator's internal temperature read 52 degrees Fahrenheit. The internal temperature probe had a Safe Range of 10 degrees Fahrenheit to 40 degrees Fahrenheit. Two medications were noted on first shelf to be Basaglar Kwikpen 10 unit/1mL Insulin Pen [medication used to control blood sugar] both medications were unopened, packaging on medication read, Refrigerate until opened. LVN F stated, the internal temperature of the medication refrigerator is higher than 50 degrees Fahrenheit, it is too warm, we store our unopened insulin in there. During a concurrent observation and interview on 2/27/24, at 2:03p.m., with LVN F, in Medication Storage Room, a new medication refrigerator was placed in spot where the refrigerator observed yesterday. LVN F stated, our maintenance staff replaced the other refrigerator because there was something wrong with the back of it when he inspected it and it was too warm inside. During a review of Basaglar Kwikpen 10 unit/1mL Insulin Pen medication storage instructions, (undated), instruction indicated, Prefilled pens: Store unopened prefilled pens under refrigeration between 2°C and 8°C (36°F and 46°F) until expiration date. During a review of the facility's Policy and Procedure (P&P) titled, Storage of Medication, dated 2020, the P&P indicated, The facility stores all drug and biologicals in a safe, secure, and orderly manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 5 of 13 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 safe and sanitary food service operations were carried out according to standards of practice when: Residents Affected - Some 1. A wet rice cooker pot was stored in the rice cooker without being air dried; and 2. The dry storage room bottom shelf was under six inches (a unit of length) off the floor. These failures had the potential to expose 27of 28 residents to harmful contaminants that could cause foodborne illness. Findings: 1. During a concurrent observation and interview on 2/26/24 at 8:42 a.m. with the Certified Dietary Manager (CDM) in the kitchen, there was a wet rice cooker pot stored inside of the rice cooker. The CDM took out the pot and stated they would wash the pot again, and it should have been air dried before storing in the rice cooker. During a review of the facility's policy and procedure (P&P) titled Dishwashing undated. The P&P indicated, 5. Dishes are to be air dried in racks before stacking and storing. 2. During a concurrent observation and interview on 2/27/24 at 10:20 a.m. with the CDM in the dry storage room. Onions and other dry goods were stored on the bottom shelf, and the bottom shelf to the floor was measured as three and half inches. The CDM stated the shelf should have been six inches above ground to prevent contamination. During a review of the facility's P&P titled Food Receiving and Storage revised November 2022. The P&P indicated, Dry food storage - 5. Food in designated dry storage areas are kept at least six (6) inches off the floor (unless packaged for case lot handling, for example, dollies, pallets, racks and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 6 of 13 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to properly dispose the garbage and did not follow the facility's policy and procedures (P&P) for Covering receptacles when one of two dumpsters did not have lids closed properly. This failure had the potential to attract pests and rodents which could lead to unsanitary conditions and spread of disease. Residents Affected - Some Findings: During an observation on 2/26/24 at 12:20 p.m. at the facility's outside dumpsters area, there was one dumpster with the lid left open. During an observation on 2/27/24 at 11:15 a.m., the same dumpster had overflowing garbage, and the lid was not closed tightly. During an interview on 2/28/24 at 3:33 p.m. with the Maintenance Supervisor (MS), the MS stated dumpsters should have been closed to prevent rodents and pests, and dumpsters were emptied every Monday, Wednesday, and Friday. During a review of the facility's policy and procedure (P&P) titled Miscellaneous Areas undated. The P&P indicated, Trash procedure: 2. Garbage and trashcans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. According to the Food and Drug Administration (FDA) Food Code 2022, section 5-501.113 titled, Covering Receptacles, and section 5-501.115 titled, Maintaining Refuse Areas and Enclosures, it indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 7 of 13 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview and record review, the facility failed to document repositioning for one out of 12 sampled residents (Resident 3) while in bed. This failure had the potential to result in inaccurate provision of care. Findings: During an observation on 02/29/24 at 9:32 a.m., Resident 3 was in bed lying on his back. During an interview on 2/29/24 at 9:42 a.m. with Certified Nursing Assistant (CNA) A, CNA A stated, Resident 3 was turned every hour. CNA A stated there was no evidence documentation when turning was completed. CNA A stated, there should have been a documentation for the turning. During an observation on 02/29/24 at 11:13 a.m., Resident 3 was lying in bed and was facing the right side. During a concurrent interview and record review on 2/29/24 at 11:14 a.m. with Licensed Vocational Nurse (LVN) B, Treatment Administration Record (TAR) dated 2/1/24- 2/29/24 was reviewed. The TAR indicated, Turn and reposition q1h (every one hour) every shift. Start date 2/16/24 1500 (3:00 p.m.). The TAR indicated check marks with initials three times daily for the rows labeled Day, Eveni, and Night. The TAR indicated check marks started on 2/16/24 for the row Eveni. LVN B stated, the turning every one hour was ordered. LVN B stated, there was no documentation when turning was done since it was ordered on 2/16/24. During a review of Resident 3's Order Summary Report dated 2/16/24 at 3:00 p.m., Order Summary Report indicated, Turn and reposition q1h (every one hour). During an interview on 2/29/24 at 3:11 p.m. with Director of Nursing (DON), DON stated, they do not have a log for turning or repositioning Resident 3. DON stated, they do not have a policy for CNA flow sheet (a record of patient care provided for each resident). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 8 of 13 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 Based on observation, interview and record review, the facility failed to implement proper infection control measures when: Residents Affected - Few 1. The Infection Preventionist (IP) did not put on a pair of disposable gloves prior to handling a urine bag. 2. Licensed Vocational Nurse (LVN) G did not perform hand hygiene during medication administration. These failures had the potential to result in spread of infection and compromise the health and safety of the residents in the facility. Findings: 1. During a concurrent observation and interview on 2/28/24 at 10:48 a.m., with Infection Preventionist (IP), in Resident 3's room, IP handled Resident 3's urine bag and tubing with bare hands. Resident 3's urine bag and tubing both visibly contained urine. Upon leaving Resident 3's room, IP touched and pressed the top of the hand sanitizer by the door to dispense product. IP stated, I should have worn gloves prior to touching the urine bag. 2. During a concurrent observation and interview on 2/28/24, at 3:36 p.m., with LVN G, in hallway by Resident 19's room, LVN G began preparing Resident 19's medication without performing hand hygiene. LVN G gave Resident 19 his medication and returned to hallway to begin preparing the next residents medication. LVN G did not perform hand hygiene after exiting Resident 19's room. LVN G stated, she forgot to use hand sanitizer before preparing medications and after exiting the room. During a review of facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene date revised August 2019, the P&P indicated, 7. Use an alcohol-based hand rub containing at least 62% alcohol;or alternatively, soap and water for the following. c. before preparing or handling medications.Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Single-use disposable gloves should be used .when anticipating contact with blood or body fluids. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 9 of 13 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 pneumococcal vaccine (vaccine to prevent bacterial pneumonia [infection of the lungs]) up to date for 10 of 15 sampled residents (Resident 3, 4, 9, 11, 12, 13, 16, 17, 19, and 27) per the Centers for Disease Control and Prevention (CDC)'s pneumococcal vaccine schedule guidelines. This failure had the potential to place residents at a high risk of acquiring and transmitting pneumonia in the facility. Residents Affected - Some Findings: Review of Resident 3, 4, 9, 11, 12, 13, 16, 17, 19, and 27 medical records, indicated all 10 residents were over [AGE] years old and their admission dates and pneumococcal vaccination statuses as follows: - Resident 3 was admitted on [DATE], the resident received Prevnar 13 (PCV13, a type of pneumococcal vaccine) on 6/17/15. - Resident 4 was admitted on [DATE], the resident received Pneumovax 23 (PPV23, a type of pneumococcal vaccine) on 5/27/11. - Resident 9 was admitted on [DATE], the resident received PCV13 on 3/3/22. - Resident 11 was admitted on [DATE], the resident received PPV23 on 1/1/17. - Resident 12 was admitted on [DATE], the resident received PPV23 on 1/1/15. - Resident 13 was admitted on [DATE], the resident received PPV23 on 4/14/22. - Resident 16 was admitted on [DATE], the resident received PPV23 on 9/11/15. - Resident 17 was admitted on [DATE], the resident received PPV23 on 3/9/21. - Resident 19 was admitted on [DATE], the resident received PPV23 on 10/20/20. - Resident 27 was admitted on [DATE], the resident received PPV23 on 10/15/15. During an interview on 2/29/24 at 1:05 p.m. with the Director of Nursing (DON) and the Infection Preventionist (IP), the DON stated those residents' were due for their pneumococcal vaccines, the IP did not administer the vaccines to those residents per CDC's schedule guidelines. The IP confirmed those residents were supposed to receive Prevnar 20 [PCV20, the most up to date pneumococcal vaccine], and the facility did not offer the vaccine to them. Review of CDC's Pneumococcal Vaccine Timing for Adults dated 3/15/23, indicated if a resident only Received PPV23, then give 1 dose of PCV15 (Prevnar 15, a type of Pneumococcal vaccine) or PCV20 at least 1 year after the most recent PPV23 vaccination. If a resident only received PCV13, then give 1 dose of PCV20 or PPV23 at least 1 year after PCV13. [Please refer to CDC website for the complete information] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 10 of 13 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policy and procedure (P&P) titled Pneumococcal Vaccine revised March 2022, the P&P indicated, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infection. 1. Prior to or upon admission, resident are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already vaccinated. [ .] 7. Administration of the pneumococcal vaccines are made in accordance with current Center for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. Event ID: Facility ID: 555757 If continuation sheet Page 11 of 13 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview and record review, the following multi-resident rooms provided less than 80 square feet per resident: Residents Affected - Some Findings: Room Total Sq. Ft. Sq. Ft./Bed No. of Beds 6 287.86 71.965 4 7 287.86 71.965 4 10 286.66 71.665 4 During observations throughout the survey, none of the rooms were observed to inhibit the staff from providing care or the residents from receiving adequate care. The staff and the residents moved freely in the rooms. The residents and staff verbalized no complaints or concerns regarding space and privacy. Continuance of the room waiver is recommended. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 12 of 13 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 555757 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Milpitas Care Center 120 Corning Avenue Milpitas, CA 95035 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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Based on interview and record review, the facility failed to ensure nurse aides (Certified Nursing Assistants: CNAs) received 12 hours of annual in-service which included dementia management and abuse prevention training for a census of 28 when documentation of the nurse aide in-services could not be provided for 2 of 4 sampled staff. This failure had the potential to affect the quality of care and services provided to the residents. Findings: During a review of CNA E's employee record (undated), the employee record indicated, CNA E was hired on 11/8/22. During a review of CNA C's employee record (undated), the employee record indicated, CNA C was hired on 2/6/23. During a concurrent interview and record review on 2/28/24, at 1:48 p.m., with Director of Staff Development (DSD), CNA E's employee record was reviewed. The employee record indicated, no competencies or in-services since start date. DSD stated, CNA E has not had any competencies or in-services since she started working in 2022. They should have competencies and in-services annually and as needed. During a concurrent interview and record review on 2/28/24, at 1:50 p.m., with DSD, CNA C's employee record was reviewed. The employee record indicated, no competencies or in-services since start date. DSD stated, CNA C had no competencies or in-services since she started working in 2023. They should have competencies and in-services annually and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555757 If continuation sheet Page 13 of 13

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Citations

25 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.

0550GeneralS&S Dpotential for harm
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
0582GeneralS&S Dpotential for harm
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
0700GeneralS&S Epotential for harm
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
0730GeneralS&S Dpotential for harm
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
0761GeneralS&S Dpotential for harm
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.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0883GeneralS&S Epotential for harm
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
0912GeneralS&S Bno actual harm
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
0947GeneralS&S Dpotential for harm
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
0814GeneralS&S Epotential for harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0032GeneralS&S Dpotential for harm
Provide primary/alternate means for communication.
0161GeneralS&S Dpotential for harm
Use approved construction type or materials.
0291GeneralS&S Dpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
0293GeneralS&S Dpotential for harm
Have properly located and lighted "Exit" signs.
0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
0344GeneralS&S Epotential for harm
Have an alternate power supply for its alarm system.
0347GeneralS&S Dpotential for harm
Properly provide smoke detection systems in areas open to corridors.
0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0363GeneralS&S Dpotential for harm
Install corridor and hallway doors that block smoke.
0741GeneralS&S Dpotential for harm
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
0918GeneralS&S Dpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0919GeneralS&S Epotential for harm
F919 - Resident Call System
Meet requirements for the use of electrical equipment.
0923GeneralS&S Dpotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.

FAQ · About this visit

Common questions about this visit

What happened during the March 1, 2024 survey of MILPITAS CARE CENTER?

This was a inspection survey of MILPITAS CARE CENTER on March 1, 2024. The surveyor cited 25 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MILPITAS CARE CENTER on March 1, 2024?

Yes, 25 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."

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.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·March 1, 2024