SANTA CLARA, CA - Federal inspectors documented multiple violations at Mission Skilled Nursing & Subacute Center during a May 2025 inspection, including inadequate infection control practices, insufficient room sizes for resident care, and missing quality oversight systems that are required to monitor staff performance and facility operations.
Infection Control Lapses Put Residents at Risk
Federal inspectors identified serious infection prevention failures that could expose residents to preventable illnesses and complications. The most concerning violation involved a Certified Nursing Assistant (CNA) who was observed feeding two residents simultaneously without performing hand hygiene between contacts during the lunch period on May 6, 2025.
When questioned about the practice, CNA F stated she "washes hands prior to feeding the residents but does not clean hands between residents when feeding two residents at the same time." This deviation from standard infection control protocols directly contradicted the facility's own Hand Hygiene policy, which explicitly requires hand cleaning "between resident contacts."
The medical significance of this violation cannot be understated. Hand hygiene between patient contacts is considered the single most important practice for preventing healthcare-associated infections. When staff members move between residents without proper hand cleaning, they can transmit bacteria, viruses, and other pathogens that cause serious infections in vulnerable populations. Nursing home residents typically have compromised immune systems due to age, chronic conditions, or medications, making them particularly susceptible to infections that healthy individuals might easily fight off.
A second infection control violation involved improper handling of intravenous equipment for a resident receiving IV hydration therapy. Licensed Vocational Nurse D confirmed that "the tip of the IV tubing was left uncapped and exposed to air while not in use," acknowledging that "it should not be like that" and "should have a small cap on the end to prevent infection."
This practice creates a direct pathway for bacteria to enter the IV system and subsequently the resident's bloodstream, potentially causing life-threatening bloodstream infections. IV-related infections can lead to sepsis, a dangerous condition where the body's response to infection causes organ dysfunction and can be fatal if not promptly treated.
Room Size Deficiencies Impact Care Quality
Inspectors found that nine of the facility's 60 rooms failed to meet federal space requirements designed to ensure adequate room for resident care and quality of life. The affected rooms—numbered 301, 302, 303, 304, 305, 309, 311, 312, and 314—each measured 13 feet by 11 feet, providing only 71.5 square feet per resident in double-occupancy rooms.
Federal regulations require at least 80 square feet per resident in shared rooms and 100 square feet for single-occupancy rooms. These standards exist for important medical and safety reasons. Adequate space is essential for healthcare workers to safely maneuver equipment such as wheelchairs, hospital beds, and emergency response devices. Insufficient room space can compromise the ability to provide proper care during medical emergencies or routine treatments.
The space deficiency also affects infection control efforts. Cramped quarters make it more difficult to maintain appropriate distances between residents during illness outbreaks and can impede proper cleaning and disinfection procedures. Additionally, adequate personal space contributes to residents' mental health and dignity, factors that significantly impact overall well-being and recovery outcomes.
While residents reported satisfaction with their room sizes during the inspection, federal standards recognize that patients may not always be aware of how space limitations could affect their care quality or safety during emergencies.
Missing Quality Oversight Systems Create Accountability Gaps
Perhaps most concerning from a systemic perspective was the facility's failure to implement required quality assurance monitoring. The facility's Quality Assurance and Performance Improvement (QAPI) plan, updated in 2017, specifically outlined requirements for quarterly personnel file audits to ensure compliance with training and documentation requirements.
However, the Administrator in Training stated during the May 9 interview that "he does not have documentation of the [Director of Staff Development] having performed random audits of personnel files" and that "the facility was not aware CNA annual performance reviews were not being completed."
This gap in oversight represents a fundamental breakdown in the facility's quality management system. Regular personnel file audits serve multiple critical functions: they ensure staff maintain current licenses and certifications, verify completion of mandatory training programs, and identify patterns that might indicate systemic problems with staff performance or facility operations.
The absence of annual performance reviews for CNAs is particularly troubling given that these staff members provide the majority of direct resident care. Performance reviews serve as opportunities to identify training needs, recognize excellent performance, and address any care quality concerns before they impact residents. Without these reviews, substandard performance may go unnoticed and uncorrected, potentially compromising resident safety and care quality.
Medical Context and Industry Standards
These violations collectively represent failures in fundamental healthcare safety principles that nursing facilities are required to maintain. Infection prevention protocols exist because healthcare-associated infections are a leading cause of preventable illness and death in long-term care settings. The Centers for Disease Control and Prevention estimates that nursing home residents experience more than 380,000 infections annually, many of which could be prevented through proper hygiene practices.
Room size requirements reflect evidence-based standards developed through decades of healthcare facility design research. Adequate space supports not only routine care delivery but also emergency response capabilities. When emergencies occur, healthcare teams need sufficient room to perform life-saving procedures, operate resuscitation equipment, and coordinate multiple staff members' efforts.
Quality oversight systems like QAPI programs are mandated because they provide the systematic monitoring necessary to maintain high care standards. These programs help facilities identify problems early, implement corrective measures, and continuously improve their operations. Without effective oversight, facilities may not recognize declining performance until serious adverse events occur.
Additional Issues Identified
The inspection also documented the facility's acknowledgment that it operates with a room size waiver, indicating ongoing awareness of the space deficiency issue. The facility reported conducting quarterly surveys with residents and families about room size concerns, with no complaints documented during recent monitoring periods.
The facility's infection control policies, dated as recently as February 2025, clearly outlined staff responsibilities for following prevention protocols, indicating that the observed violations represented implementation failures rather than absent policies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mission Skilled Nursing & Subacute Center from 2025-05-09 including all violations, facility responses, and corrective action plans.
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