Cycle 1
Health 2025-05-09 · Fire 2025-05-09
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
San Jose, CA
Canyon Springs Post-Acute
3-star overall rating with 2-star inspections with 18 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
180 North Jackson Avenue, San Jose, CA
(408) 259-8700
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
199
Certified beds
Average residents
190
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1994-12-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.43
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.60
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
6%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,131
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.70% · Performance 22.29% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.68% · Performance 12.09% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.16
Baseline 54.84% · Performance 38.51% · Measure score 6.16 · Achievement 6.16 · Improvement 4.95
Adjusted total nurse staffing
1.01
Baseline 3.71 hours · Performance 3.37 hours · Measure score 1.01 · Achievement 1.01 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 228 · Observed rate 8.77% · Lower 95% interval 7.01% |
| Discharge to community | 47.58% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 233 · Observed rate 39.91% · Lower 95% interval 41.06% |
| Medicare spending per beneficiary | 1.56 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 206 · Denominator 206 |
| Falls with major injury | 0.49% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 206 |
| Discharge self-care score | 61% |
53.69%
7.3 pts better
|
Numerator 61 · Denominator 100 |
| Discharge mobility score | 61% |
50.94%
10.1 pts better
|
Numerator 61 · Denominator 100 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 206 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 12.09% |
7.12%
5 pts worse
|
Worse than the National Rate · Eligible stays 179 · Observed rate 15.64% · Lower 95% interval 7.58% |
| Staff COVID-19 vaccination coverage | 32.96% |
8.2%
24.8 pts better
|
Numerator 59 · Denominator 179 |
| Staff flu vaccination coverage | 69.23% |
42%
27.2 pts better
|
Numerator 180 · Denominator 260 |
| Discharge function score | 68% |
56.45%
11.5 pts better
|
Numerator 68 · Denominator 100 |
| Transfer of health information to provider | 99.21% |
95.95%
3.3 pts better
|
Numerator 125 · Denominator 126 |
| Transfer of health information to patient | 61.9% |
96.28%
34.4 pts worse
|
Numerator 13 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 43.3% |
25.2%
18.1 pts better
|
Numerator 42 · Denominator 97 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.3
1.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.5 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.6
0.5 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
98.5%
1.4 pts better
|
93.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.4% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
1.6%
0.6 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.1% · Q3 1.2% · Q4 1.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.9% |
6.8%
0.9 pts better
|
11.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.6% · Q3 9.7% · Q4 4.0% · 4Q avg 5.9% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
4.1%
3 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.2% · Q3 0.6% · Q4 0.6% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.9% |
13.7%
7.8 pts better
|
19.6%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 5.9% · Q3 6.7% · Q4 4.8% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.6% |
14.2%
10.6 pts better
|
16.7%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.8% · Q3 1.9% · Q4 4.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.7% |
11.0%
6.3 pts better
|
16.3%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 2.8% · Q3 2.5% · Q4 6.7% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.5% |
10.7%
9.2 pts better
|
14.9%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 0.7% · Q4 1.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.2%
0.7 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.5% |
10.9%
2.4 pts better
|
19.8%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 11.7% · Q3 4.2% · Q4 8.2% · 4Q avg 8.5% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.7%
2.9 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.5% · Q3 1.6% · Q4 1.8% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
94.0%
5.6 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
11.2%
2.3 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 10.3% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.5%
1.1 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
23.2%
4 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 32.3% · Expected 28.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-15 · Fire 2024-02-15
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
30 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Cycle 3
Health 2021-06-14 · Fire 2021-06-14
31 health deficiencies
Top issue: Quality of Life and Care (11 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-31
F · Potential for more than minimal harm
2025-05-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-05-09
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-05-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-05-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-05-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-05-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-09
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-03
E · Potential for more than minimal harm
2025-05-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-03
D · Potential for more than minimal harm
2025-05-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-03
C · Minimal harm
2025-05-09
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-06-03
C · Minimal harm
2025-05-09
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-06-03
F · Potential for more than minimal harm
2024-02-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-16
F · Potential for more than minimal harm
2024-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-16
F · Potential for more than minimal harm
2024-02-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-02-15
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-02-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-02-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-02-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-02-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-02-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-16
F · Potential for more than minimal harm
2021-06-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-07-15
E · Potential for more than minimal harm
2021-06-14
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2021-07-15
E · Potential for more than minimal harm
2021-06-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-07-15
E · Potential for more than minimal harm
2021-06-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-07-15
E · Potential for more than minimal harm
2021-06-14
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2021-07-15
D · Potential for more than minimal harm
2021-06-14
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-07-15
D · Potential for more than minimal harm
2021-06-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-07-15
D · Potential for more than minimal harm
2021-06-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-07-15
D · Potential for more than minimal harm
2021-06-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-15
D · Potential for more than minimal harm
2021-06-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-07-15
D · Potential for more than minimal harm
2021-06-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-07-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-29
D · Potential for more than minimal harm
2025-06-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-26
F · Potential for more than minimal harm
2025-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-09
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-09
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-05-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-05-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-30
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-05-12
E · Potential for more than minimal harm
2025-01-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-06-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-26
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-26
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-02-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-15
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-04
D · Potential for more than minimal harm
2023-11-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-16
E · Potential for more than minimal harm
2023-03-29
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-29
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-03-18
G · Actual harm
2021-06-14
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2021-07-26
F · Potential for more than minimal harm
2021-06-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-14
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-14
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-14
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-14
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-07-26
E · Potential for more than minimal harm
2021-06-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-14
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-14
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-14
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-06-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-07-26
Penalties and ownership
What sits behind the stars
Ownership
Hudson River Opco LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Bay Bridge Capital Partners, LLC
5% Or Greater Indirect Ownership Interest · Organization
Bennett, John
Operational/Managerial Control · Individual
Bennett, John
W-2 Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Vetsa, Surekha
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Vista Manor Nursing Center
San Jose, CA
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Inspire Behavioral Health
San Jose, CA
2-star overall rating with 1-star inspections with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
San Jose Healthcare & Wellness Center
San Jose, CA
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out