F-F730).
Findings:
During a review of the facility's QAPI Plan, updated 2017, QAPI plan indicated, Quality Surveillance Data. Education/In-Service Tracking, Responsible for Review/reporting to Committee Director of Staff Development, Action Plan(s) required for: Federal/State required in-services not completed per regulations, personnel files audits that result in negative findings. QAPI Plan indicated, Random personnel file reviews should occur quarterly to determine compliance with training and documentation requirements as well as mandatory hiring criteria and license verification. Results of random audits should be reviewed by the Executive Director with training summary and audit findings reported to the QA&A [QAPI] Committee for
review and process improvement.
During an interview on 5/9/25, at 9:23 a.m., with the Administrator in Training (AIT), the AIT stated, he does not have documentation of the DSD having performed random audits of personnel files. AIT stated the facility was not aware CNA annual performance reviews were not being completed.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 055645 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055645 B. Wing 05/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Mission Skilled Nursing & Subacute Center 410 North Winchester Boulevard Santa Clara, CA 95050
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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44577 potential for actual harm Based on observation, interview and record review, the facility failed to ensure staff were implementing Residents Affected - Some infection prevention practices when:
1. One of four Certified Nursing Assistances (CNA) failed to perform hand hygiene between residents during dining;
2. Resident 309's intravenous (IV, to deliver a medication into a vein) tubing tip left uncapped when not in use.
During an observation on 05/06/25 at 12:53 p.m., Certified Nursing Assistant (CNA) F, was in the dining room sitting between Resident 5 and Resident 44 feeding them both lunch without cleaning her hands between Residents.
During an interview on 05/06/25 at 3:07 p.m., 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.
Review of the facility's policy and procedure titled Hand Hygiene, dated 5/29/24 indicated, Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .Between resident contacts.
Review of the facility's policy and procedure titled Infection Prevention and Control Program, dated 2/5/25 indicated, All staff are responsible for following all policies and procedures related to the program.
50135
Review of Resident 309 's clinical record indicated Resident 309 was admitted on [DATE REDACTED] with diagnoses including post digestive system (a group of organs in the body that break down food into its simplest forms) surgery care, severe protein-calorie malnutrition, and status post gastrostomy (GT tube, a surgical opening into the stomach for the administration of nutrition and medications).
Review of the Order Summary Report for Resident 309 indicated a physician order dated 5/4/25 for 0.45% sodium chloride (low salt fluid) intravenous sodium solution. Use intravenously every shift for IV hydration (provides fluid to the body when food by mouth is insufficient or not possible.
During a concurrent observation and interview on 5/7/25 at 9:55 a.m. with Licensed Vocational Nurse D (LVN D) inside Resident 309's room, LVN D confirmed the tip of the IV tubing was left uncapped and exposed to air while not in use. LVN D stated, It should not be like that. LVN D also stated, It should have a small cap on
the end to prevent infection.
Review of the facility's policy and procedure titled, Infection Prevention and Control Program, dated 2/5/25 indicated, All staff are responsible for following all policies and procedures related to the program.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 055645 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055645 B. Wing 05/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Mission Skilled Nursing & Subacute Center 410 North Winchester Boulevard Santa Clara, CA 95050
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 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm 46939
Residents Affected - Some Based on observations and interviews, the facility failed to ensure all multiple-resident bedrooms provided at least 80 square feet per resident for 9 of 60 rooms observed.
This failure had the potential for Residents in rooms #301, #302, #303, #304, #305, #309, #311, #312, and #314 to have less space available for daily care and assistance.
Findings:
During observations from 5/5/25 to 5/9/2025 in rooms #301, #302, #303, #304, #305, #309, #311, #312, and #314., each room was a two-resident room and measured 13 feet by 11 feet, resulting in a total square footage of 143 square feet, or 71.5 square feet per resident. During the observation, residents reported they had plenty of space and did not have concerns with the size of their rooms.
During an interview on 5/5/25 at 8 am with the Administrator, the Administrator, stated social services asks
the residents or their families each quarter if there were any problems with the room size and none had been reported. The Administrator indicated the smaller room size did not inhibit resident care, and the facility has a room waiver.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 055645