Morgan Hill Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to follow their discharge policy for one of three sampled residents (Resident 1) when Resident 1 was not allowed to return to the facility after a doctor's appointment. This failure had the potential to compromise Resident 1's health and safety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, provision of care and services related to pressure ulcers were consistent with professional standards of practice for one of 14 sampled residents (Resident 22), when there were no proper description and measurements of the pressure ulcer of Resident 22 in her weekly wound assessments. These failures had the potential for the residents with pressure ulcers, not being properly monitored and treated which could delay the healing or worsen the wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted for on the medication administration record (MAR) to indicate they were given for three out of six residents (Residents 13, 39, and 49) showed that medications were signed out of the Antibiotic or Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). This failure had the potential for access to medications and supplies by unauthorized persons such as residents and visitors.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 9.68%, when three medication errors out of 31 opportunities occurred during medication administrations for two of four residents (Residents 7 and 13) as follow: 1. Resident 7 missed to receive Gabapentin (medication used for nerve pain) and Docusate Sodium (DSS-stool softener used to treat and prevent constipation) during medication pass observation; and 2. Resident 13 was given Xarelto (Rivaroxaban - used to treat or prevents blood clots) 20 milligram (mg, metric unit of measurement) medication without meal. These deficient practices resulted in medications not being given in accordance with the prescriber's orders and/or manufacturer's specifications, which could have resulted in the residents not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medication for one of one medication storage room and one of two medication carts, when: 1. Three blister pack of Buspirone HCL (used to treat anxiety disorder) 5 milligram (mg-unit of dose measurement) has expired on 2/2/25; 2. Two vials of tuberculin purified protein (Aplisol- a sterile aqueous solution of purified protein fraction for intradermal administration used in the diagnoses of tuberculosis) with no open date written on the vial; 3. A bottle of Latanoprost 0.005% (used to treat glaucoma [a condition in which increased pressure in the eye can lead to gradual loss of vision]) eye drop with expiration date of 4/7/25; 4. A bottle of Ciprofloxacin 0.3 % (used to treat infections of the eye) eye drop with no open date written on the bottle; 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, kitchen equipment were sanitary and dishwashing chemicals and garbage containers were stored in accordance with professional standards for food safety when: 1. There were kitchen large pan trays and kitchen equipments that were unsanitary; and 2. Dishwashing chemicals and garbage containers in the kitchen were not stored safely and properly. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the food recipes for making puree (smooth, crushed or blended food that's made by breaking down solid foods into a creamy paste or liquid) were being followed when the cook did not follow the recipes for making pureed baked beans and deluxe coleslaw. These failures had the potential to lead in decreased food palatability that could decrease the food consumed by residents which could lower the nutrient intakes for the eight residents on puree diet order out of fifty-one facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures when one out of 14 sampled Residents (Resident 6's) nasal cannula was not replaced in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure multiple rooms had at least 80 square feet per resident. Having less than 80 square feet per resident had the potential to compromise the care and services the residents receive.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure treatment and care provided were in accordance with professional standards of practice when vital signs monitoring was not done for one (Resident 1) out of two sampled residents. This failure resulted in unrecognized decline of Resident 1's physical and mental status that led to hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure appropriate and timely treatment and care was provided to one of three sampled Residents (Resident 1) when Resident 1 was only seen by a hand surgeon 33 days from the date of the Physician's order for the referral for possible osteomyelitis (inflammation or swelling that occurs in the bone caused by infection). This failure resulted in Resident 1's left middle finger amputation (surgical removal of a body part) and hospitalization that put Resident 1 at risk for sepsis (a life-threatening complication of an infection).

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: 1. There were opened and undated food items in the reach-in refrigerator; 2. There was a dented can on the food preparation table; 3. The kitchen staff were not following their policy for checking dishwasher temperature and sanitizing frequency. These failures had the potential to cause food contamination and food-borne illness to 45 of 45 residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, safe, comfortable, and homelike environment for five of 14 sampled residents (Residents 6, 47, 40, 44 and 41) when: 1. Resident 6's privacy curtain was not properly hooked to the rod; 2. Resident 47's privacy curtain had a dark red stain; 3. Resident 40's privacy curtain had a white stain; 4. Resident 44's room was cold; 5. Resident 41's room was cold; and 6. Facility hallways, lobby, and dining room temperatures were not maintained within the range of 71 to 81 degrees Fahrenheit (a scale for measuring temperature). These failures had the potential to result for residents decreased sense of well-being, and exposed to an uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate safety monitoring for four of 14 sampled residents (Resident 16, 31, 37, and 38) when the wanderguard device was not checked for proper functioning. This failure had the potential for the alarm system to not work and increase the risk for elopement (leave a facility without staff knowledge).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for one of six residents (Resident 101) on respiratory treatment when: 1. The licensed nurse failed to ensure oxygen was administered as specified in the physician's order; 2. The facility staff failed to monitor Resident 101's shortness of breath as specified in the physician's order for more than two months. These failures had the potential to compromise Resident 101's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily staffing information posted was the current date. This failure had the potential to result in nurse staffing misinformation to the residents, family and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices when: 1. Certified nursing assistant D (CNA D) did not perform hand hygiene when assisting two residents (Residents 16 and 24) with meals; 2. Licensed vocational nurse A (LVN A) did not perform hand hygiene in between glove changes during Resident 47's wound treatment; 3. Certified nursing assistant G (CNA G) practiced double gloving (wearing of inner and outer gloves) during Resident 47's incontinent care; and 4. Resident 10's urinary drainage bag was found lying on the floor. These failures had the potential to compromise resident's health and safety in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat two of 14 sampled residents (Resident 16 and 10) with respect and dignity when: 1. Certified nurse assistant D (CNA D) was standing while feeding Resident 16 in the social dining area; and 2. Resident 10's urinary drainage bag was not covered with a privacy bag. These failures had the potential to negatively affect resident's emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident's care needs were accommodated for two of 14 sampled residents (Resident 47 and 40) when Resident 47 and Resident 40's call light buttons were not within reach to use. These failures had the potential to affect residents' physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's rights to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) when licensed nurse left the computer screen open and unattended on top of the medication cart. This failure had the potential to compromise the resident's privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification to the Office of the State Long-Term Care Ombudsman (LTCO - person who routinely visits the facility and advocates for the residents in the nursing homes) for 28 out of 31 discharged residents reviewed when: 1. Resident 49 went for dialysis and was transferred to the hospital; 2. Resident 50 was transferred to the hospital; and 3. Social service director (SSD) failed to notify the State LTCO for 26 more resident discharges in a period of 3 months (September-[DATE]). This failure had the potential to compromise the resident's admission, transfer, and discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to encode and transmit in a timely manner the Minimum Data Set (MDS- a tool used for resident assessment) for two of 14 sampled residents (Resident 29 and 14) when: 1. The MDS nurse (MDSN) used a wrong assessment reference date (ARD - date of the MDS assessment) for Resident 29's Skilled Nursing Facility Part A Prospective Payment System Discharge Assessment (SNF Part A PPS DC - a required assessment to determine resident's last day of skilled services and resident's current status); and 2. Resident 14's two MDS Entry Tracking's were transmitted to the Center for Medicare and Medicaid System (CMS) late. These failures resulted in wrong ARD MDS assessment submitted to CMS and Entry Tracking's not received by CMS within the time requirement.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents at risk for pressure injuries (an area of skin that breaks down when something keeps rubbing or pressing against the skin) received care, consistent with professional standards of practice to prevent pressure injuries for one of three residents (Resident 40) at risk for pressure injuries when licensed nurses did not follow Resident 40's doctor's order to prevent pressure injuries and did not update Resident 40's care plan. These failures had the potential to result in Resident 40's development of pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate communication with the dialysis center for one of two residents on dialysis (Resident 21), when the communication form sections which are to be filled out by the facility and dialysis center was not completed. This failure had the potential to result in Resident 21's negative health outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure controlled substance medications (those with high potential for abuse and addiction) were accurately accounted for on the Medication Administration Record (MAR) and the Controlled Drug Record (CDR) for one of three randomly selected residents (Resident 44). This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of this medication.

Inspectors wroteBased on interview and record review the facility failed to ensure the pharmacist's medication regime review (MMR) recommendations for one of 14 sampled residents (Resident 16) were acted upon. This failure had the potential to negatively affect the residents' health and well-being.

Inspectors wroteBased on observation, interview and document review, the facility failed to comply with Federal and State laws, and regulations when the approval letter for staffing waiver was not posted where visitors, family and residents could easily read. This failure had the potential to result in nurse staffing misinformation about residents' care.

Inspectors wroteBased on observation and interview, the facility failed to ensure that part of a handrail in the hallway was firmly affixed and secured to the wall. This failure had the potential to cause injuries to residents, staff, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure multiple rooms had at least 80 square feet per resident. Having less than 80 square feet per resident had the potential to compromise the care and services the residents receive.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the proper sanitization levels of the dishwasher and 2-compartment sink, when kitchen staff did not properly check the sanitizer strength in the dishwasher nor in the 2-compartment sink. This failure had the potential of causing a facility-wide food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their infection control practices and precautions when: 1. Facility staff did not ensure visitors were thoroughly screened for signs and symptoms of Covid-19 (an acute respiratory illness in humans caused by a coronavirus, capable of producing severe symptoms and in some cases death, especially in older people and those with underlying health conditions) and did not give directions on screening; 2. Facility staff did not clean and disinfect the thermometer in the screening area after each use; and 3. One facility staff did not perform hand hygiene before glove use. These failures have the potential to spread infection and to compromise the health and well-being of the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four controlled medications ( medications included in the Drug Enforcement Administration) which are subject to special handling, storage, disposal and record keeping in the facility) had been accurately accounted for in the two of two medication carts checked when the amount of medications counted from the blister cards (a pharmacy-prepared paperboard with medications in individual doses that can be punched out of the card when administered) were not consistent with the narcotic count sheet for three controlled medications, and one controlled medications was signed out before dispensing and administering the medication to resident. These failures had the potential to create problems related to accounting of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 12 sampled residents (Residents 20, 25 and 29) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors, example is antipsychotics) when: 1. Resident 20 had no informed consent signed prior to the administration of Duloxetine (Cymbalta, antidepressant). 2. Resident 25 did not have a documented clinical rationale or justification for the continued use of Olanzapine (antipsychotic- medication used to manage psychosis including delusion or hallucinations)when the recommended GDR was declined by her primary care physician (PCP). 3. Resident 29, did not have an informed consent signed for the dose increase of Seroquel (used to treat certain mental/mood disorders) from 50mg. ( milligrams, unit of measurement) to 75mg. per day. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare the puree meals to meet the nutritive value needed for 9 of 9 residents who receive a puree diet, when: 1. the cook added water and thickener to the pureed vegetables, 2. the bread and cake, which were on the menu, were not pureed nor served to the residents who are on a puree diet. These failures had the potential of the residents who received a puree diet to not receive the appropriate nutrients/calories.

Inspectors wroteBased on observation and interview, the facility failed to 1. properly label the arrival and/or open date of foods in the kitchen and 2. to keep MedPass formula at proper temperature, when - onions were in a clear bin unlabeled, - three clear containers of pastas were unlabeled, - four open boxes of breakfast cereal were unlabeled, - packets of hot chocolate mix and low calorie instant lemon drink were unlabeled, and - containers of MedPass formula were on medication carts for extended periods without proper refrigeration. These failures had the potential of causing food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 20's personal request to have a darker window cover/blinds/shades to prevent eye glare, and to have a over bed light cord string were accommodated; and facilty failed to honor Resident 20's food preferences. These failures resulted in Resident 20's discomfort, and feeling stressed and irritated; and had the potential to result in patient not being able to maintain or achieve independent functioning, dignity, and well being to the extent possible in accordance with the resident's own needs and preferences.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to notify the Office of the State Long-Term Care Ombudsman of Resident 29 being transferred twice to the hospital. This failure had the potential of Resident 29 being incorrectly transferred.

Inspectors wroteBased on interview and record review, the facility failed to develop and update the care plans for three of 12 sampled residents (Residents 14, 20 and 28). For Resident 14, there was no care plan developed for scattered skin rashes on her several body parts. For Resident 20, there was no care plan developed for Cymbalta (antidepressant); and the care plan was not revised/updated or implemented for depression to reflect the change of medications, and ambulation. For Resident 28, there was no care plan developed regarding the presence of left eye conjuntivitis; the care plan for impaired visual function was not implemented. A personalized care plan identifies residents' individualized concerns/needs that outlines the care and services needed to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services according to professional standards of practice for two of 12 sampled residents (Residents 19 and 40). When Resident 19's Depakote (medication to treat certain seizures, mania caused by bipolar disorder) level every 6 months and Resident 40's EKG (electrocardiogram, measures the heart's electrical activity) every 6 months while on Nuplazid (indicated for the treatment of hallucinations and delusions associated with Parkinson's disease psychosis) were not done as ordered. These failures could negatively affect the resident's health, safety, and well-being in the facility.

Inspectors wroteA review of Resident 28's facesheet indicated admission on [DATE]. Her MDS dated [DATE] and 5/5/22 indicated impaired vision and difficulty hearing. During an observation on 6/27/22 at 10:09 a.m., Resident 28 was in bed awake, watching TV without any sounds. Resident 28 claimed she had no hearing aid and had difficulty with hearing but could not turn the TV loud enough to hear because the facility would not allow it. Resident claimed she could not reach for her headphones which were hung near the TV set and staff did not offer it to her. Resident 28 also indicated she loved reading books, and she stated, I can't read because of the problem in my eyesight. Resident 28 stated she and her daughter were concerned about her eye and wanted to see the eye specialist. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide a restorative nurse assistant (RNA) program (nursing intervention to assist or promote resident's ability to attain their maximum functional potential) for two residents (20, 28). These failures had the potential to compromise the residents' ability to attain their maximum functional potential and result in a decline of resident's health.

Inspectors wroteBased on interview and record review, the facility failed to ensure the proper functioning of a wander guard (a device worn on a resident or their mobility equipment to warn staff of resident possibly leaving the facility) for one resident (Resident 32). This failure has the potential of a resident eloping (leaving the facility without staff's knowledge), and potentially being harmed or killed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed pharmacist performed a monthly Medication Regimen Review (MRR) for one of four residents (Resident 29) when Resident 29 was missing some monthly MRRs. This failure had the potential of residents being administered incorrect medications.

Inspectors wroteBased on observation, interview, and record review, the facility had a 7.14% (percent) error rate when two medication errors out of 28 opportunities were observed during a medication pass. These failures resulted in the medications not being administered according to the physician orders and the manufacturer's specifications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the licensed nurses stored, disposed/discard medications per manufacturer's recommendations when: 1. One multi-dose vial of tuberculin solution (drug use to help diagnose tuberculosis)was dated when opened. 2. One pack of Tylenol (analgesic and antipyretic-for fever) suppository (inserted via rectum) was not stored together with Refresh eye drops (drug used to lubricate dry eyes). 3. One bottle of Fluticasone nasal spray (drug used to relieve symptoms of rhinitis such as sneezing and a runny, stuffy nose) opened on 5/18/22 was disposed/discarded from the medication cart. 4. One container of Breo Ellipta (drug used for asthma) 100-25 mcg. (micrograms, unit of measurement) inhaler opened on 4/10/22 , marked by pharmacy discard after 42 days from opened date was disposed beyond the discard date. 5. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the Resident' 20s food allergy was considered, and dislikes were followed. This failure could compromise and affect Resident 20's clinical condition and could potentially result in complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure multiple rooms had at least 80 square feet per resident. Having less than 80 square feet per resident had the potential to compromise the care and services the residents receive.