Gilroy Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure to provide care and services to meet professional standards for one of three sampled resident (Resident 1) when license nursing staff failed to follow medical doctor's (MD, a licensed healthcare professional who practices medicine to diagnose, treat, and prevent illnesses, injuries, and other medical conditions for residents) order to notify the MD when Resident 1's blood glucose (BG, sugar level in blood) level were more than 300 (mg/dl, milligrams per deciliter, standard unit of measuring BG) for 14 times across nine days in two months. These failures had the potential to affect plan of care, medical condition and well-being for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary medication. Resident 1 received insulin (a man- made medication used to treat high blood glucose [BG, sugar in blood] level) without documented evidence of adequate monitoring for signs and symptoms (s/s) of hypoglycemia (a medical condition with blood glucose drops to dangerous low levels) and hyperglycemia (a medical condition with high blood glucose level) on routine basis for Resident 1. These failures had the potential to affect health condition, well-being and necessary use of insulin for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure to follow their policy and procedure (P&P) for prevention of pressure injuries (localized damage to the skin and underlying soft tissue when exposed to prolonged or intense pressure) for one of three sampled resident (Resident 1) when there was no documented evidence indicated for Resident 1's braden assessment (a standardized, evidence-based clinical tool used by healthcare professionals to predict a resident's risk of developing pressure injuries) completed upon admission to the facility on 9/29/2025. This failure had the potential to affect pressure injury management for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure to explain in a form and manner that resident was able to understand before signed an arbitration agreement (a contract that requires to resolve future disputes with facility through a private arbitration process, waive the right to sue the facility for issues) for one of three sampled resident (Resident 2). This failure had the potential to compromise the right to be fully informed to make health care choices, decisions, and well-being for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to code minimum data set (MDS: an assessment tool) assessment accurately for range of motion (ROM: joint flexibility/movement either independently or with assistance) with contractures (a condition affecting joint stiffness or tightness causes severe limitations with joint movements) for one of 3 sampled resident (Resident 1). This failure had the potential to affect inappropriate care and treatment for contractures for Resident 1.

Inspectors wroteBased on interview, and record review , the facility failed to ensure 67 out of 67 residents (residents who received Levaquin [a brand name for levofloxacin, a type of antibiotic known as fluoroquinolone used to treat bacterial infections] and Metformin [a medication that helps control the amount of glucose (sugar) in the blood]) (Residents 392, 389, 122, 130, 127, 124, 383, 393, 132, 83, 126, 391, 125, 129, 388, 68, 7, 10, 82, 52, 41, 394, 123, 390, 70, 384, 21, 387, 133, 93, 74, 385, 326, 381, 103, 47, 377, 222, 89, 49, 46, 106, 131, 323, 16, 22, 33, 63, 50, 23, 386, 128, 111, 322, 4, 71, 80, 99, 15, 382, 2, 64, 26, 17, 380, 90, and 65) were free from unnecessary medications when there was inadequate monitoring and systemic failure in management of residents on medications with black box warning (BBW, is the strongest warning the Food and Drug Administration [FDA-it is a federal [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their policy and procedure (P&P) for completion of physician orders for life-sustaining treatment (POLST: a document that specifies the medical treatments the resident wants to receive during serious illness) form for six of eight sampled residents (Resident 34, 42, 57, 83, 104 and 106). This failure could lead to the delivery of unnecessary or inappropriate medical services against sampled residents' goals and wishes.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive care plans that included target symptoms, measurable objectives, and interventions for nine out of 26 sampled residents (Resident 5, Resident 96, Resident 109, Resident 10, Resident 106, Resident 111, Resident 89, Resident 91, and Resident 52) when: 1. Resident 5 had no care plan developed related to nebulization treatment (using a machine called a nebulizer to convert liquid medicine into a fine mist that can be inhaled into the lungs); 2. Resident 96 had no care plan developed for diagnosis of epilepsy (an abnormal activity in the brain causing uncontrollable jerking movements of the arms and legs, and loss of consciousness); 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 18.18% when 6 medication errors occurred out of 33 opportunities during the medication administration for three out of eight residents (Resident 52, 106, and 112). For Resident 106, the nursing staff did not prime (the process of removing air from the insulin pen and needle before each injection) the insulin (medication to lower blood sugar) pen and needle before giving insulin. Resident 112 received fluticasone nasal spray (a medication for seasonal allergies) not as ordered. Resident 52 received 4 medications that were combined, crushed, administered together via the gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach), a practice contrary to the facility's policy and procedures (P&P). [...]

Inspectors wroteBased on observation and interview the facility failed to ensure food served was palatable and attractive. This failure had the potential to affect the amount of food residents consume, which could decrease their food intake and lead to poor nutrition and health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when pans used for food preparation and food service were stacked and stored wet. This failure had the potential to cause food contamination and food-borne illness to 117 of 118 residents who received their food from the kitchen.

Inspectors wrote5. On [DATE] at 9:19 a.m., Licensed Vocation Nurse (LVN) C was observed removing a glucometer from the medication cart. On [DATE] at 9:22 a.m., at Resident 5's bedside, LVN C was observed pricking the resident's left middle finger to get a blood sample for the blood sugar reading. On [DATE] at 9:28 a.m., LVN C was observed removing a pre-saturated chlorox disinfectant wipe and wrapping it around the glucometer without wipping it down first. Then she placed it on top of the medication cart. On [DATE] at 9:38 a.m., LVN C used the same glucometer and entered Resident 106's room to obtain his blood sugar reading. She stated she could not get a reading because the battery in the glucometer died. Two minutes later, on [DATE] at 9:40 a.m., LVN C returned to the medication cart, and again, used the chlorox disinfectant wipe to wrap around the glucometer without cleaning it first with the wipe. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their Antibiotic Stewardship Program when six of 18 residents (Residents 89, 68, 108, 23, 47, and 373) who received antibiotics (medications that kill or inhibit the growth of bacteria) did not meet the Loeb's criteria [a set of minimum clinical guidelines used in long-term care facilities (LTCFs) to help healthcare providers decide when to initiate antibiotic treatment for suspected infections in residents]. These failures had the potential to increase the prevalence of multi-drug resistance organism (MDRO - these are microorganisms, mostly bacteria, that have become resistant to multiple types of antibiotics) or bacteria.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needs were accommodated for three of 26 sampled residents (Residents 100, 96, and 52) when: 1. Resident 100 and Resident 96's call light button (a red or white button used to call for assistance) were not within their reach for use; and 2. Resident 52 did not receive the appropriate call system (a device used to communicate a need for help) based on his needs. These failures had the potential for a delayed response and not meeting Resident 100, Resident 96 and Resident 52's needs.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the residents were made aware of the location of the latest facility's State inspection result (Statement of Deficiencies and Statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent extended surveys, and any deficiencies resulting from any subsequent complaint investigations) and available to read for six out of seven residents (Residents 34, 7, 55, 88, 68, and 71). This failure had the potential to result in residents being uninformed.

Inspectors wroteBased on observation, interview, and facility's document review, the facility failed to maintain resident's rights to privacy and confidentiality to three of 26 sampled residents (Resident 371, Resident 372, and Resident 373) when: 1. Resident 371's Foley catheter drainage bag, (a device inserted into the bladder [organ that collects urine] to drain urine, made of a semi-flexible plastic tube, one end inserted into the bladder and the other end attached to a bag that collects urine) drain bag was left uncovered; and 2. Resident 372 and Resident 373's personal information and care instructions were posted in the room visible to roommate and visitors. These failures had the potential to compromise resident's rights and dignity.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure 2 of 5 sampled residents (Residents 14 and 21) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 21 received a high dose of quetiapine (generic: Seroquel: an antipsychotic medication, used to regulate the functioning of brain circuits that control thinking, mood, and perception) without documented necessity for its use and without demonstration of how the behavioral symptoms caused harm to the resident/others or causing significant distress to the resident; 2. Resident 14 received Seroquel and Fluoxetine (an anti-depressant) with no documented non-drug interventions for both medication; 3. Resident 83 received pro re nata (PRN: [...]

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for two residents (83 and 119) when: 1. For Resident 119, the facility failed to accurately complete the discharge status; 2. For Resident 83, the facility did not code the use of injectable medication and incorrectly coded Resident 83's falls. Failure to accurately assess the residents had the potential to result in inadequate or inappropriate care planning and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to provide necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new pressure injuries/ulcers (injury to skin from prolonged pressure on the skin) from developing for one of four sampled resident (Resident 57) when: 1. No dressing on right outer ankle pressure injury for Resident 57; 2. No prevalon (a medical device designed to prevent and treat heel pressure injury/ulcer) heel protector boot on to right foot for Resident 57. Above failures had the potential for delayed pressure ulcer healing and developing new pressure injuries for Resident 57.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (those with a high abuse potential) were fully accounted when controlled medication use audit for three out of seven sampled residents (Residents 53, 106, and 109) did not reconcile. The residents' medications were signed out of the Controlled Drugs Records (CDR, inventory record of controlled drugs) but not documented on the Medication Administration Record (MAR, record of medications administered to a resident) to indicate they were administered to the residents. The failure resulted in inaccurate accountability and had the potential for abuse and diversion (unlawful distribution or use) of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the medication regimen review (MRR) for one out of 26 sampled residents (Resident 373) when Resident 373 had two similar orders for Dilaudid (brand name for hydromorphone, a potent opioid medication used to treat moderate to severe pain). This deficient practice had the potential for excessive dose/adverse effects for Resident 373.

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (RP, a person designated to make decisions on behalf of a resident) of resident's change of condition for one of three sampled residents (Resident 1). This failure had the potential to affect the ability of the RP to participate in the planning of resident's care and treatment plans.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to ensure Level 1 Preadmission Screening and Resident Review (PASARR) was accurately completed upon admission for 1 (Resident #36) of 3 sampled residents reviewed for PASARRs.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1), when the facility failed to report an injury of unknown source with serious bodily injury (injury requiring medical intervention such as surgery) to the California Department of Public Health (CDPH) within 2 hours after the facility known about the injury of Resident 1. This failure had the potential for Resident 1's injury of unknown source to not be investigated thoroughly and be at risk for continued injury.

Inspectors wrote2. During a concurrent observation and interview on 4/19/21 at 4:25 p.m., LN H was not wearing his facemask while in the nursing station with another staff. When asked if he needed to wear his facemask, he stated he could not answer the surveyor. During an interview with the director of nursing (DON) on 4/19/21 at 4:43 p.m., she stated staff were expected to wear a face mask while in the facility. According to the Centers for Disease Control and Prevention website https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, Health care provider (HCP) should wear well-fitting source control (e.g facemasks or respirators) at all times while they are in the healthcare facility. 3. During an observation 4/20/21 at 8:54 a.m., LN F wore gloves while preparing medications. LN F went to room (rm) X to talk with a resident without taking off her gloves. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the State Long Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) was notified in writing in a timely manner for 16 out of 16 discharged residents (Residents 133, 130, 135, 128, 175, 136, 176,138, 65, 132, 125, 127, 126 and 131). This failure had the potential of not providing the resident and/or their responsible party (RP, a person who is accountable in making decision in behalf of the resident) with an access to an advocate who could inform them of their rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine and accurate administerstration of medications for one of 23 sampled residents (Resident 10), and accurate accountability of controlled substance (CS, drugs with high potential for abuse or addiction) medications for three of four random record reviews (Residents 80, 112, and 229), when: 1. Resident 10, who had recent eye surgery, did not routinely receive two of her eye medications as ordered on 4/19 and 4/20/21. This had the potential for delay in treatment for the resident; 2. The nursing staff did not document medication administration and did not give routine medications to Resident 10 in a timely manner for two days in April 2021; and, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's consultant pharmacist (CP) failed to identify and make recommendations to the facility regarding drug storage concerns and irregularities related to the residents' drug regimen for four of 23 sampled residents (Residents 32, 47, 80, and 117). The failures resulted in inadequately monitored medications, which could lead to unsafe and ineffective medications for residents, and unnecessary medications for the residents, which had the potential to place them at risk for harm or adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six of 23 sampled residents (Residents 9, 32, 47, 70, 80, and 117) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 9 received five doses of as-needed lorazepam (a controlled medication to treat agitation and anxiety) when the nursing staff documented no behaviors observed, and there was no documented evidence the resident exhibited behaviors before receiving the lorazepam doses; 2. Resident 32 received Seroquel (an antipsychotic medications) with inadequate monitoring when there was no Abnormal Involuntary Movement Scale (AIMS; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and label medications in accordance with the manufacturer's instructions and the facility policy and procedures when: 1. One vial of insulin (medication to treat high blood sugar) and one vial of flu vaccine were found in active stock past their discard date; and 4 multi-dose vials (medication, usually in liquid, intended for more than one dose of medication), one oral inhaler, and 3 Xalatan (or lanatoprost, to treat high pressure inside the eye due to glaucoma) eye solution bottles were opened without an open date. Two of the Xalatan eye solutions for 2 residents were being used past the discard date. 2. A Lantus (long-acting insulin) vial was identified without patient-specific label; 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to respond to residents' call lights in a timely manner for three of 23 sampled residents (Residents 49, 62, and 70), when: 1. Resident 62 waited 25 minutes in the bathroom to get transfer assistance from wheelchair to toilet to urinate. 2. Resident 70 waited ten minutes for her to be turned and repositioned in bed, and 3. Resident 49 waited ten minutes to get a drink. This failure resulted in the delayed response to residents' needs and could potentially cause resident emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their abuse policy for three of three sampled residents (Residents 16,18, and 56) when, 1. Residents 16, 18, and 56 were not protected from physical and verbal abuse by certified nursing assistant M (CNA M) and, 2. Residents' 18 and 56 allegations of abuse were not reported. These failures put the residents at risk for further abuse.

Inspectors wroteBased on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for two of 23 sampled residents (Residents 27 and 230) when the MDS did not reflect the current status of the residents. This failure had the potential to affect inappropriate care planning and intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were provided to meet the professional standard of practice for three of 23 sampled residents when: 1. Resident 12's input and output was not measured and documented appropriately; 2. Resident 70 and Resident 117's physician orders for the use of oxygen was not followed. These failures had the potential to affect the residents' health condition and care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 117) was free from unnecessary medications when the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of blood thinning medications. Resident 117 was receiving Lovenox (generic name enoxaparin, an anti-coagulant, or blood thinning medication) and Plavix (anti-platelet agent to prevent heart attacks or strokes). This had the potential for side effects of these medications (such as bleeding, excessive bruising, etc.) to go undetected or recognized for timely intervention.

Inspectors wroteBased on observation, interview, and record review, the facility had a 7.14% error rate when two medication errors out of 28 opportunities were observed during the medication pass. Resident 10 did not receive an eye medication as scheduled; and the nursing staff administered eye medications not in accordance with the facility's medication administration guideline and accepted professional standards of practice. The failure resulted in medications not given as ordered and as per accepted professional standards of practice, which may negatively affect the resident's health.