Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gilroy Healthcare Center during CMS and state inspections, most recent first.
A resident with intact cognitive function was asked by a CNA to sign an arbitration agreement related to new facility ownership. The CNA, who had not received training on the agreement, provided only a minimal explanation, stating the resident could not sue the facility, and did not answer further questions. The resident signed the agreement without understanding its contents, contrary to facility policy requiring clear explanation.
A resident with quadriplegia and contractures in both upper and lower extremities was observed to have significant limitations in movement, as confirmed by therapy and medical documentation. However, the MDS assessment was inaccurately coded to indicate no impairment in range of motion, contrary to direct observations and staff interviews.
A systemic failure occurred when all residents receiving Levaquin or Metformin did not have required Black Box Warning (BBW) monitoring or care plans documented, and many lacked appropriate indications for antibiotic use. Nursing staff inconsistently documented BBW monitoring, with only day shift nurses seeing alerts, and evening and night shifts not consistently involved. The Infection Preventionist and Consultant Pharmacist did not identify or report these irregularities, resulting in widespread noncompliance with facility policy and regulatory requirements.
Six residents had POLST forms with the advance directive section left blank, despite facility policy requiring all sections to be completed. The DON confirmed that nursing staff did not complete these sections as required by policy.
Multiple residents did not have required care plans developed or implemented for conditions such as nebulizer therapy, epilepsy, helmet use, respiratory issues, infection, and anticoagulant therapy. Staff confirmed that care plans were missing despite physician orders and clinical needs, and one resident's call bell system was not assessed or adapted to their physical limitations.
Surveyors observed multiple medication administration errors, including failure to prime an insulin pen before injection, incorrect dosing of a nasal spray, and combining multiple crushed medications for G-tube administration instead of administering them separately with flushing. These actions were not in accordance with facility policies and physician orders.
Multiple residents reported that meals were bland, repetitive, and unappetizing, with specific complaints about tasteless and dry eggs served daily. During a test tray evaluation, surveyors, the RD, and the DM found the green beans to be overcooked, lacking flavor, and visually unappealing. Job descriptions for dietary staff required them to ensure food was appealing and to monitor food acceptance, but these standards were not met.
Surveyors found that metal pans used for food preparation and service were stacked and stored while still wet, rather than being air dried as required by professional standards. The dietary manager confirmed the improper storage, which had the potential to affect nearly all residents receiving food from the kitchen.
Surveyors identified multiple infection control deficiencies, including improper cleaning and disinfection of glucometers and medication trays, failure to wear required PPE during enteral medication administration, and improper storage and labeling of nebulizer kits, nasal cannulas, and basins. Additional lapses included soiled linen left on the floor, missing Enhanced Barrier Precautions signage for a resident with a pressure ulcer, and urinary catheter drainage bags touching the floor, all contrary to facility policy.
Six residents received antibiotics without meeting Loeb's criteria, with antibiotics prescribed for symptoms such as confusion, knee pain, or abdominal pain, and in some cases, without documented assessment or appropriate clinical indications. Antibiotics were started before culture results were available, and some prescribed antibiotics were not effective against the identified bacteria. The facility's antibiotic stewardship protocols and interdisciplinary oversight were not consistently followed.
Three residents with significant physical and cognitive impairments did not have accessible or appropriate call light systems, as their call light buttons were found on the floor and out of reach, and one resident was not provided with a suitable alternative call system despite being bedbound and unable to use the standard device. Staff confirmed the deficiencies, and facility policy required call lights to be accessible and tailored to individual needs.
The facility did not ensure that residents could easily access or were informed about the location of the latest State survey results. Multiple residents reported not knowing where to find the survey results, and staff interviews and observations confirmed that the required binder was not available in the designated area, contrary to facility policy.
Surveyors found that a resident's Foley catheter drainage bag was left uncovered and visible from the hallway, and two residents had personal care instructions posted openly in their rooms, making sensitive information visible to others. Staff confirmed these actions did not comply with facility policies requiring privacy and confidentiality.
The facility did not ensure that psychotropic medications were used only when necessary, as evidenced by two residents receiving antipsychotic and antidepressant medications without proper documentation of behavioral symptoms or attempts at non-drug interventions, and another resident receiving PRN lorazepam without a required stop date or physician reassessment. Staff and DON interviews confirmed the lack of documentation and adherence to facility policy regarding psychotropic medication use.
The facility did not accurately complete MDS assessments for two residents, resulting in incorrect documentation of discharge status, injectable medication use, and fall history. One resident was incorrectly coded as discharged to a hospital instead of home, while another had missing documentation of weekly SQ injections for diabetes and inaccurate fall reporting. These errors were confirmed by the MDS staff and DON during record reviews and interviews.
A resident with a right outer ankle pressure ulcer was found in bed without a dressing on the wound and without a Prevalon heel protector boot in place, despite physician orders for both. Staff confirmed the omission during observation, and records showed the required treatments and devices were not applied as ordered, resulting in a deficiency in pressure ulcer care.
Nursing staff did not consistently document the administration of PRN controlled medications on the MAR after signing them out from the CDR for three residents with physician orders for narcotic pain medications. This resulted in incomplete records and inaccurate accountability of controlled substances, as confirmed by the DON and ADON during record review and interviews.
A resident with type 2 diabetes had two similar orders for Dilaudid (hydromorphone) and a Fentanyl patch, but the Consultant Pharmacist did not identify or report the duplicate opioid orders during the monthly medication regimen review. The duplicate orders were confirmed by nursing staff, and records showed the resident received more than the maximum allowed dose of hydromorphone in one day.
Failure to Adequately Explain Arbitration Agreement Prior to Resident Signature
Penalty
Summary
The facility failed to ensure that a resident was provided with an adequate explanation of an arbitration agreement in a form and manner the resident could understand prior to obtaining her signature. A certified nursing assistant (CNA) approached the resident and requested her electronic signature for the arbitration agreement, which was related to a change in facility ownership. When the resident asked for clarification, the CNA only stated that signing meant she could not sue the facility and did not provide further explanation. The CNA also admitted to not having received any education or training from the facility regarding the arbitration agreement or how to explain it to residents. The resident, who had diagnoses including depression, hypertension, and type 2 diabetes, was assessed as having intact memory and full mental capacity at the time of the incident. Documentation confirmed that the resident was alert and oriented, and her medical records indicated she was capable of understanding information presented to her. Despite this, the resident signed the agreement without understanding its contents, as the explanation provided was insufficient. Facility policy required that such agreements be explained in a manner understood by the resident or their representative, but this was not followed in this instance.
Inaccurate MDS Coding for Range of Motion with Contractures
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for a resident with significant contractures and quadriplegia. Observations revealed that the resident had curled fingers on the right hand, contractures in the left wrist, and both ankles, and was unable to move both hands and legs. Interviews with the resident confirmed the inability to open fingers or hold objects due to joint restrictions, and no movement in both legs. The resident's medical history included quadriplegia and cerebrovascular disease, with occupational therapy notes and physician documentation confirming impaired range of motion (ROM) in both upper and lower extremities due to contractures. Despite this, the resident's MDS assessment indicated no impairment for upper or lower extremity ROM. Interviews with the Director of Rehabilitation and the MDS Coordinator confirmed the presence of contractures and impaired ROM, and acknowledged that the MDS assessment was inaccurately coded. The facility's policy requires comprehensive and accurate assessments of each resident's functional capacity, but this was not followed in this case, resulting in an inaccurate MDS assessment for ROM.
Systemic Failure to Monitor and Document Black Box Warning Medications
Penalty
Summary
Surveyors identified a systemic failure in the facility's management of medications with FDA Black Box Warnings (BBW), specifically Levaquin (levofloxacin) and Metformin, affecting all residents who received these drugs. For 54 residents who received Levaquin and 19 residents who received Metformin, there was no documentation that BBW monitoring was performed, and no care plans were developed addressing the BBW risks associated with these medications. Additionally, 30 residents who received Levaquin did not have an appropriate indication or diagnosis documented for its use. Six residents received both Levaquin and Metformin without proper BBW monitoring or care plans. These failures were confirmed through record reviews, interviews with staff, and examination of the facility's policies and procedures. Interviews with nursing staff, the Infection Preventionist (IP), and the Director of Nursing (DON) revealed inconsistencies and gaps in understanding and implementing BBW monitoring. While the facility's policy required nursing progress notes to reflect monitoring and resident response to BBW medications, staff interviews indicated that only the day shift nurse administering the medication would see the BBW alert, and documentation in progress notes was inconsistent or absent. Evening and night shift nurses were not consistently alerted or documenting BBW monitoring. Multiple resident records reviewed showed no evidence of BBW monitoring in either the Medication Administration Record (MAR) or nursing progress notes, despite ongoing or recent administration of Levaquin or Metformin. The facility's Infection Preventionist and Consultant Pharmacist failed to identify and report irregularities related to frequent Levaquin use, missed BBW monitoring, inappropriate antibiotic indications, and lack of care plans during their respective reviews. The deficiency was observed across all shifts and affected all residents prescribed these medications during the review period. The lack of monitoring and documentation was confirmed for multiple residents with complex medical histories, including those with kidney disease, diabetes, infections, and other serious conditions, as evidenced by detailed record reviews and staff interviews.
Incomplete POLST Forms for Multiple Residents
Penalty
Summary
The facility failed to ensure that the Physician Orders for Life-Sustaining Treatment (POLST) forms were fully completed for six out of eight sampled residents. Specifically, the section regarding advance directives (AD) was left blank on the POLST forms for these residents. Record reviews showed that, despite the residents' admissions and the preparation of their POLST forms, the required section for documenting advance directives was not filled out. This omission was confirmed during a concurrent record review and interview with the Director of Nursing (DON), who acknowledged that nursing staff should have completed all sections of the POLST forms. Facility policies and procedures require that a completed and fully executed POLST form is a legal physician order and must be immediately actionable. Additionally, the policies state that any decision-making regarding a resident's choices should be documented in the medical record and communicated. The failure to complete the advance directive section on the POLST forms for these residents represents noncompliance with these established policies.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for nine out of 26 sampled residents, as required by policy and professional standards. Specific deficiencies included the absence of care plans for residents receiving nebulization therapy, those with a diagnosis of epilepsy and prescribed anti-seizure medication, and residents requiring the use of a craniotomy helmet, including documentation of non-compliance with helmet use. Additionally, care plans were missing for residents experiencing wheezing or shortness of breath, those with active infections, and residents prescribed blood thinners such as Eliquis and Warfarin. Surveyors observed and confirmed through interviews and record reviews that these omissions occurred despite clear evidence in the residents' clinical records and physician orders indicating the need for such care plans. For example, residents with new or ongoing respiratory issues were receiving nebulizer treatments or inhaled medications without corresponding care plans. Similarly, residents with significant neurological or cardiovascular diagnoses, such as epilepsy or atrial fibrillation, were prescribed critical medications without individualized care plans addressing their conditions or the use of these medications. Further, the facility did not assess or document appropriate call bell system needs for a resident with significant physical limitations, resulting in the call light being inaccessible and not tailored to the resident's abilities. Staff interviews confirmed that care plans were not initiated or updated in a timely manner, and that the responsibility for care planning was not consistently fulfilled by the nursing staff, including the MDS nurse, ADON, and DON. Facility policies required comprehensive, person-centered care plans with measurable objectives and timeframes, but these were not developed or implemented for the affected residents.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility was found to have a medication error rate of 18.18% during medication administration observations, with 6 errors identified out of 33 opportunities involving three residents. For one resident with diabetes, an LVN failed to prime the insulin pen before administering a 40-unit dose of insulin degludec, despite facility policy and manufacturer instructions requiring priming to ensure accurate dosing. The LVN acknowledged the omission during an interview, and both the DON and consultant pharmacist confirmed that priming is required before each use. Another resident was prescribed fluticasone nasal spray with instructions to administer two sprays in each nostril daily. During observation, an LVN administered only one spray per nostril. Upon review of the physician's order and facility policy, the LVN confirmed the error and acknowledged the correct dose should have been given as ordered. A third resident, who received medications via a gastrostomy tube, was administered four different crushed medications combined together in a single dose, contrary to facility policy. The RN responsible for the administration admitted that each medication should have been crushed and administered separately with appropriate flushing between medications. The DON and consultant pharmacist both confirmed that medications should not be mixed together for enteral administration, and the facility's policy requires separate administration and flushing.
Failure to Provide Palatable and Attractive Food to Residents
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and met expectations for taste and presentation. Multiple residents reported dissatisfaction with the meals, describing them as bland, lacking flavor, repetitive, and unappetizing. Specific complaints included breakfast being tasteless and monotonous, with eggs served daily that were described as dry and flavorless. These concerns were voiced by several residents during interviews conducted on the same morning. In response to these complaints, a test tray evaluation was conducted during a lunch service, with participation from the registered dietician (RD), dietary manager (DM), and surveyors. The green beans served as an alternate vegetable were found by surveyors to be unappealing in appearance, lacking color, overcooked, and without flavor. Both the DM and RD agreed with these assessments, with the DM noting the green beans were mushy and flavorless, and the RD stating they did not look appetizing enough to taste. Review of job descriptions for the cook and RD confirmed their responsibilities included ensuring appealing food presentation and monitoring food acceptance, which were not met in this instance.
Wet Stacking of Food Preparation Pans
Penalty
Summary
During a kitchen tour, surveyors observed 11 metal pans of various sizes stored under the steam table, stacked upside down inside one another while still wet on both the inside and outside surfaces. The dietary manager confirmed that the pans were wet and acknowledged that they should have been air dried before being stacked and stored. This practice did not comply with the 2022 FDA Food Code, which requires equipment and utensils to be air-dried after cleaning and sanitizing, and to be stored in a self-draining position that allows air drying. The failure to properly air dry and store the pans had the potential to affect 117 of 118 residents who received food from the kitchen.
Multiple Infection Control Deficiencies Observed
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. One nurse was seen using a glucometer on multiple residents without properly cleaning and disinfecting it according to manufacturer and facility policy. The nurse wrapped the glucometer in a disinfectant wipe without wiping it down first, and did not ensure the required wet contact time. Additionally, the same nurse failed to disinfect a medication tray between uses for different residents, despite facility policy requiring all reusable items to be cleaned between uses. Another nurse did not wear a gown during enteral tube medication administration, contrary to the facility's Enhanced Barrier Precautions policy, which requires both gloves and gowns for such procedures. Further deficiencies were noted in the handling and storage of resident care equipment. Used nebulizer kits, masks, and tubing were found unlabeled, undated, and improperly stored among residents' personal belongings or in plastic bags on nightstands. Staff interviews revealed inconsistent knowledge of cleaning, labeling, and replacement protocols for these items, with some staff unsure of the correct procedures or frequency of changes. Similar issues were observed with nasal cannulas, which were left uncovered, undated, and not stored in plastic bags when not in use. Used basins were also found unlabeled and stored inappropriately in shared bathrooms, and a bag of soiled towels was left on the floor outside the soiled linen room, both in violation of facility policy. Additional infection control lapses included the absence of Enhanced Barrier Precautions signage for a resident with a stage 3 pressure ulcer, and urinary catheter drainage bags observed touching the floor in two separate resident rooms. Staff confirmed that these practices did not align with facility policies, which require catheter bags to be kept off the floor and signage to be posted for residents requiring enhanced precautions. These observed failures were corroborated by staff interviews and a review of facility policies, all of which outlined proper procedures that were not followed during the survey period.
Failure to Follow Antibiotic Stewardship Program and Loeb's Criteria
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program by administering antibiotics to six residents who did not meet the Loeb's criteria for initiating antibiotic therapy. In multiple cases, antibiotics were prescribed and administered based on symptoms that did not align with established clinical guidelines, such as confusion, knee pain, or abdominal pain, without the presence of fever, dysuria, or other specific signs of infection. Documentation revealed that antibiotics were started before culture results were available, and in some instances, the prescribed antibiotics were not effective against the identified microorganisms, as shown by culture results indicating resistance. For example, one resident with Alzheimer's disease and a history of UTI was given levofloxacin for suspected UTI despite only exhibiting knee pain and increased confusion, with no fever or urinary symptoms. Another resident with paralysis of the vocal cords and diabetes received levofloxacin for pharyngitis based solely on a fever and sore throat, without further documented assessment or additional symptoms. Additional residents received antibiotics for confusion, abdominal pain, or asymptomatic bacteriuria, again without meeting the minimum clinical criteria for antibiotic initiation. Interviews with the Infection Preventionist (IP) and review of records confirmed that the facility's antibiotic stewardship meetings were infrequent, and there was a lack of consistent interdisciplinary oversight. The IP acknowledged awareness of the inappropriate antibiotic use but deferred to physician decisions, and the medical director confirmed a practice of prescribing antibiotics preemptively while awaiting culture results. The facility's policy required adherence to evidence-based criteria and monitoring of antibiotic use, but these protocols were not consistently followed, as evidenced by the findings.
Failure to Ensure Accessible and Appropriate Call Light Systems for Residents
Penalty
Summary
The facility failed to ensure that the needs and preferences of three residents were reasonably accommodated, specifically regarding the accessibility and appropriateness of call light systems. For two residents with significant cognitive and physical impairments, the call light buttons were observed on the floor and out of reach while the residents were in bed. One resident, who had a history of spinal fracture and moderate cognitive impairment, was unable to access his call light and stated he did not know how long it had been on the floor. Another resident, with severe cognitive impairment and right-sided hemiplegia, was also unable to locate his call light, which was confirmed by staff to be on the floor. Staff interviews revealed that there should have been clips to secure the call lights within reach, and facility policy required call lights to be accessible to residents at all times. A third resident, who was bedbound with left-sided hemiplegia and aphasia following a stroke, was found to have a call light button hanging from urinary catheter tubing and resting on the floor, making it inaccessible. Staff confirmed that this resident never used the standard call light button and acknowledged that a different call system would have been more appropriate given the resident's limited movement and high dependency. Facility policy required that residents be evaluated for unique needs and that special accommodations, such as alternative call systems, be provided and documented in the care plan. These failures were identified through direct observation, resident and staff interviews, and record reviews. The lack of accessible and appropriate call systems for these residents had the potential to delay staff response and did not meet the residents' needs as required by facility policy and procedure.
Failure to Make State Survey Results Readily Available to Residents
Penalty
Summary
The facility failed to ensure that residents were made aware of the location of the latest State inspection results, including the Statement of Deficiencies and any subsequent survey findings. During a Resident Council meeting, six residents stated they were not aware of where to find the survey results and had not been informed by facility staff. Observations in the front lobby and at multiple nurse stations revealed that the State inspection results were not posted or available in the designated areas, and the binders present did not contain or indicate the survey results. Interviews with staff, including the activities supervisor, administrator, unit clerk, registered nurse, certified nursing assistant, and DON, confirmed that the survey results binder was not available in the lobby as required by facility policy. Staff members were either unaware of the binder's location or unable to provide clear information about its whereabouts. The facility's policy stated that the survey binder should be located in the main lobby and available for review, but this was not being followed at the time of the survey.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of three residents' personal and medical information. For one resident with muscle weakness and benign prostatic hyperplasia, surveyors observed that the resident's Foley catheter drainage bag was left uncovered on two separate occasions, making the contents visible from the hallway. The privacy curtains were open, and the drainage bag, containing yellow urine, was not concealed with a privacy bag as required by facility policy. Staff confirmed that the catheter bag should have been covered to protect the resident's privacy and dignity. Additionally, two other residents had personal care instructions posted openly in their shared rooms, making sensitive information visible to roommates and visitors. One resident had a large sign above the head of the bed instructing staff to remove and replace dentures, while another had two signs regarding the use of a neck brace and caution during care. Both residents were aware of the postings, and staff confirmed that such instructions should be covered or placed in a manner that maintains privacy. Facility policies reviewed by surveyors emphasized the importance of protecting residents' privacy and confidentiality in these situations.
Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications for multiple residents. One resident with Alzheimer's disease and dementia was administered a high dose of quetiapine (Seroquel) for reported auditory hallucinations, but there was no documentation in the clinical record specifying the nature of these hallucinations or evidence that they caused harm or significant distress. Observations and interviews with staff and the resident's family indicated that while the family reported past behavioral symptoms, there was no current documentation or monitoring of such symptoms in the facility records to justify the ongoing use of the medication. Another resident with bipolar disorder and depression was prescribed both Seroquel and fluoxetine, but the clinical record lacked evidence that non-drug interventions were attempted prior to administering these psychotropic medications. The Director of Nursing confirmed that nursing staff did not document any non-pharmacological approaches before medication administration, as required by facility policy. A third resident with depression received PRN lorazepam without a stop date, and the clinical record did not show that a physician had reassessed the need for continued use of the medication after 14 days, as required. The DON acknowledged the absence of physician re-evaluation and documentation for the ongoing PRN order. Facility policies require non-pharmacological interventions to be attempted and PRN psychotropic orders to be time-limited unless properly justified, but these procedures were not followed for the residents involved.
Inaccurate MDS Assessments for Discharge, Medication, and Falls
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, resulting in incorrect documentation of discharge status, medication administration, and fall history. For one resident, the discharge MDS was coded as a transfer to an acute hospital, despite physician orders and staff confirmation that the resident was discharged home with medications and home health services. This discrepancy was verified during a record review and interview with the Minimum Data Set Manager, who acknowledged the error and confirmed the resident was not discharged to a hospital as recorded. For another resident, the MDS assessment failed to document the use of injectable medication, despite physician orders and electronic medication administration records showing weekly subcutaneous injections for diabetes. Additionally, the MDS inaccurately recorded the resident's fall history, listing both a fall with no injury and a fall with injury, when only a fall with no injury was documented in the incident reports. These inaccuracies were confirmed by the Minimum Data Set Coordinator Manager and the Director of Nursing during interviews and record reviews, who both stated that the MDS assessments should have been completed accurately according to facility policy and the RAI Manual.
Failure to Provide Ordered Pressure Ulcer Care and Preventive Devices
Penalty
Summary
A deficiency occurred when a resident with a right outer ankle pressure injury was observed in bed without a dressing on the wound and without a Prevalon heel protector boot on the right foot. Certified nursing assistant (CNA) and registered nurse (RN) both confirmed during separate observations that the resident's pressure injury was not covered as ordered, and the heel protector boot was not in use, despite being present on the nightstand. The CNA acknowledged forgetting to verify and apply the boot, while the RN confirmed that the dressing had not been applied to the pressure injury at the time of observation. Record review showed that there were physician orders in place for daily cleansing and dressing of the pressure ulcer, as well as for the use of a Prevalon heel protector boot to the right foot. The facility's policy required redistribution of pressure and evidence-based treatments for residents with pressure injuries. The failure to follow these orders and policies resulted in the resident not receiving necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries.
Failure to Document Administration of Controlled Medications
Penalty
Summary
Nursing staff failed to accurately document the administration of controlled medications for three out of seven sampled residents. In each case, staff signed out controlled medications such as hydrocodone-acetaminophen and oxycodone from the Controlled Drugs Records (CDR), but did not record the administration on the Medication Administration Record (MAR). This discrepancy was identified during a review of the CDRs and MARs for residents who had physician orders for as-needed (PRN) narcotic pain medications. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the medications were signed out but not documented as administered on the MAR, and acknowledged that this documentation was required by facility policy. The facility's policies require that nursing staff sign the MAR after administering medications and maintain accurate controlled substance records, including the date, time, and signature of the person administering the medication. The DON stated that staff sometimes become busy and forget to document on the MAR, but confirmed that all controlled medications must be accounted for on the MAR. The failure to document these administrations resulted in inaccurate accountability of controlled substances for the affected residents.
Failure to Identify and Report Duplicate Opioid Orders During Medication Regimen Review
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities during the monthly medication regimen review for one resident. Specifically, the resident was admitted with a diagnosis of type 2 diabetes mellitus and had two similar physician orders for Dilaudid (hydromorphone), both prescribed at the same dose and frequency, as well as an order for a Fentanyl patch. The orders included Dilaudid 2 mg, 4 tablets by mouth every 3 hours as needed for pain, and hydromorphone 8 mg, 1 tablet by mouth every 3 hours as needed for pain, with a maximum of 4 tablets per day. The duplicate orders were not identified or reported as irregularities in the medication regimen review conducted by the CP. Interviews and record reviews confirmed that the duplicate orders existed and were not addressed in the MRR. The CP acknowledged during an interview that the duplicate order was missed and should have been recommended for discontinuation. Additionally, a review of the controlled drug records showed that the resident received hydromorphone 8 mg five times in one day, exceeding the maximum ordered dose. The facility's policy required a thorough evaluation of the medication regimen to prevent, identify, report, and resolve medication-related problems, which was not followed in this instance.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Gilroy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morgan Hill Healthcare Center | 8.7 mi | ★★★★★ | 1 | 0 |
| Pacific Hills Post Acute | 8.8 mi | ★★★★★ | 22 | 0 |
| Manresa Healthcare Center | 12.5 mi | ★★★★★ | 12 | 0 |
| Watsonville Nursing Center | 13 mi | ★★★★★ | 12 | 0 |
| Watsonville Post Acute Center | 13 mi | ★★★★★ | 10 | 0 |
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