Report
TheVardellReport
A Grace Sub Acute & Skilled Care
Skilled nursing facility and nursing facility
1250 S. Winchester Boulevard
San Jose, CA 95128
Report
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The Vardell Report.A Grace Sub Acute & Skilled Care
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- San Jose, CA
- Record Period
- 2019–2025
- Source Documents
- 8
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 7 inspections from June 2019 to August 2025, state surveyors documented 47 findings at A Grace Sub Acute & Skilled Care; 47 have a recorded correction; CMS lists no enforcement action in the window.
- Inspections
- 7
- 2019–2025, complaint and standard
- Findings
- 47
- Deficiencies cited by state inspectors
- Corrected
- 47
- Of 47 findings, with a recorded correction date
- Penalties
- 0
- No fines or payment denials in the window
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2019 | 1 | 15 | 0 |
| 2020 | 0 | 0 | 0 |
| 2021 | 0 | 0 | 0 |
| 2022 | 1 | 15 | 0 |
| 2023 | 1 | 1 | 0 |
| 2024 | 3 | 15 | 0 |
| 2025 | 1 | 1 | 0 |
| 2026 | 0 | 0 | 0 |
What the Record Shows
- 47 of 47 findings have a recorded correction date.
- CMS lists no fines or payment denials in this window.
- 4 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, October 18, 2024, recorded 13 findings (most serious: Level E).
What to Ask About
- Pharmacy Services, Cited in Four Inspections
- Medication Error Rate, Cited in Three Inspections
- Infection Control, Cited in Three Inspections
- Citation F552, Cited in Two Inspections
- Needs and Preferences, Cited in Two Inspections
- Professional Standards, Cited in Two Inspections
- Quality of Care, Cited in Two Inspections
- Mobility and Range of Motion, Cited in Two Inspections
- Citation F756, Cited in Two Inspections
- Psychotropic Medications, Cited in Two Inspections
- Medication Labeling and Storage, Cited in Two Inspections
- Kitchen and Food Safety, Cited in Two Inspections
Report at a Glance
- Facility
- A Grace Sub Acute & Skilled Care
- Address
- 1250 S. Winchester Boulevard, San Jose, CA 95128
- CMS Certification Number
- 056376
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 166
- Ownership
- For profit - Corporation
- Record Window
- June 7, 2019 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2025
Complaint investigation
1 finding
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Sep 4, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
13 findings
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Nov 8, 2024
- F700Try 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.Level ENo actual harm, potential for moreCorrected Nov 8, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Nov 8, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Nov 8, 2024
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Nov 8, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Nov 8, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Nov 8, 2024
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Nov 8, 2024
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Nov 8, 2024
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Nov 8, 2024
- F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Nov 8, 2024
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.Level DNo actual harm, potential for moreCorrected Nov 8, 2024
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level DNo actual harm, potential for moreCorrected Nov 8, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 10, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 11, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
1 finding
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jan 29, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2022
Standard health inspection
15 findings
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected May 25, 2022
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected May 27, 2022
- F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected May 27, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected May 26, 2022
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 3, 2022
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected May 16, 2022
- F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected May 25, 2022
- F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected May 25, 2022
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected May 27, 2022
- F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected May 25, 2022
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected May 25, 2022
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected May 13, 2022
- F758Implement 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.Level DNo actual harm, potential for moreCorrected May 13, 2022
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected May 13, 2022
- F790Provide routine and 24-hour emergency dental care for each resident.Level DNo actual harm, potential for moreCorrected May 27, 2022
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2019
Standard health inspection
15 findings
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jun 26, 2019
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F693Ensure 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.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F758Implement 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.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F761Ensure 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.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level DNo actual harm, potential for moreCorrected Jun 26, 2019
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Pharmacy Services, Cited in Four Inspections
Inspectors cited F755 in June 2019, May 2022, October 2024 and August 2025. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F755 across all 7 inspections, oldest to newest - 2
Medication Error Rate, Cited in Three Inspections
Inspectors cited F759 in June 2019, May 2022 and October 2024. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F759 across all 7 inspections, oldest to newest - 3
Infection Control, Cited in Three Inspections
Inspectors cited F880 in June 2019, May 2022 and October 2024. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F880 across all 7 inspections, oldest to newest - 4
Citation F552, Cited in Two Inspections
Inspectors cited F552 in June 2019 and May 2022. The agency describes it this way: Ensure that residents are fully informed and understand their health status, care and treatments. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F552 across all 7 inspections, oldest to newest - 5
Needs and Preferences, Cited in Two Inspections
Inspectors cited F558 in May 2022 and October 2024. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F558 across all 7 inspections, oldest to newest - 6
Professional Standards, Cited in Two Inspections
Inspectors cited F658 in May 2022 and October 2024. This citation covers whether the home’s services meet professional standards of quality. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F658 across all 7 inspections, oldest to newest - 7
Quality of Care, Cited in Two Inspections
Inspectors cited F684 in December 2023 and July 2024. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F684 across all 7 inspections, oldest to newest - 8
Mobility and Range of Motion, Cited in Two Inspections
Inspectors cited F688 in June 2019 and May 2022. This citation covers care that keeps or improves a resident’s movement and mobility. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F688 across all 7 inspections, oldest to newest - 9
Citation F756, Cited in Two Inspections
Inspectors cited F756 in May 2022 and October 2024. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F756 across all 7 inspections, oldest to newest - 10
Psychotropic Medications, Cited in Two Inspections
Inspectors cited F758 in June 2019 and May 2022. This citation covers how psychotropic drugs are used, including dose reductions and limits on as-needed orders. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F758 across all 7 inspections, oldest to newest - 11
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in June 2019 and May 2022. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F761 across all 7 inspections, oldest to newest - 12
Kitchen and Food Safety, Cited in Two Inspections
Inspectors cited F812 in May 2022 and October 2024. This citation covers how food is stored, prepared and served. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
19222324242425F812 across all 7 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in four inspections, most seriously at level E.
- 02
How are medication passes checked, and what happens when an error is found?
Medication Error Rate: cited in three inspections, most seriously at level E.
- 03
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level E.
- 04
What changed after F552 was cited, and how do you check it now?
Citation F552: cited in two inspections, most seriously at level D.
- 05
How do you adjust rooms, schedules and routines to a resident’s needs and preferences?
Needs and Preferences: cited in two inspections, most seriously at level D.
- 06
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in two inspections, most seriously at level E.
- 07
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level D.
- 08
What do you do to keep residents moving, and who provides range-of-motion care?
Mobility and Range of Motion: cited in two inspections, most seriously at level D.
- 09
What changed after F756 was cited, and how do you check it now?
Citation F756: cited in two inspections, most seriously at level D.
- 10
How many residents take psychotropic medications, and how often are doses reviewed for reduction?
Psychotropic Medications: cited in two inspections, most seriously at level D.
- 11
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level D.
- 12
May we see the kitchen, and what do your own sanitation checks look like week to week?
Kitchen and Food Safety: cited in two inspections, most seriously at level E.
- 13
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 14
Has the home been fined or had payments denied before this record begins?
CMS lists no fines or payment denials in this window. The record starts June 7, 2019; anything earlier is not in it.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the California state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Jun 7, 2019 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection May 13, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Dec 28, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Mar 14, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Jul 9, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Oct 18, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
California state survey agency
Inspection Aug 14, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 056376
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowJune 7, 2019 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before June 2019 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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