Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Morgan Hill Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was denied re-entry to the facility after leaving for a medical appointment, as staff incorrectly treated the situation as an AMA discharge without physician notification or proper documentation. The resident was left outside for an extended period and ultimately transported to the hospital, with the incident documented as suspected abandonment.
A resident with a chronic stage 4 sacral pressure ulcer did not have proper weekly wound assessments documented by nursing staff, as required by facility policy. The assessments repeatedly lacked essential details such as wound measurements, color, drainage, odor, and pain, despite the resident's complex medical condition and need for close monitoring.
Nursing staff failed to document the administration of controlled medications on the MAR after signing them out from the CDR for three residents receiving PRN pain and migraine medications. This resulted in several doses of Butalbital-APAP-CAFF, Hydrocodone-Acetaminophen, and Tramadol not being properly accounted for, as confirmed by the RNC and Pharmacy Consultant.
Surveyors identified a medication error rate of 9.68% when two residents did not receive medications as ordered: one resident missed scheduled doses of gabapentin and docusate sodium, and another was given Xarelto without food, contrary to the prescriber's instructions. Nurses involved acknowledged the errors, and facility policy requires medications to be administered as ordered and per manufacturer guidelines.
Surveyors found expired medications, improperly labeled vials, unrefrigerated insulin, and unsegregated oral and ophthalmic drugs during inspections of medication carts and storage rooms. Staff confirmed that discontinued medications were not removed from active carts, and a medication cart drawer was found unclean. These practices did not follow facility policies for medication storage, labeling, and segregation.
Kitchen equipment, including trays, racks, and containers, were found with discoloration and rust, and dishwashing chemicals and garbage containers were improperly stored next to food items and utensils. These conditions were acknowledged by dietary staff and did not meet the facility's own sanitation and storage policies.
Staff did not follow standardized recipes for pureed baked beans and deluxe coleslaw, adding thickener not called for in the recipes. This affected eight residents on pureed diets, with the issue confirmed by the cook, dietary supervisor, and RD.
A resident's nasal cannula used for oxygen therapy was not replaced on a weekly basis as required by both physician orders and facility policy. An LVN confirmed the tubing had not been changed as scheduled, resulting in a lapse in infection control practices.
Surveyors identified that several multi-bed rooms provided less than the required 80 square feet per resident, with some rooms offering as little as 63.01 square feet per person. No care issues related to room size were reported by staff or residents during the survey.
A resident with multiple diagnoses, including Parkinson's Disease and a psychotic disorder, experienced an unrecognized decline in health due to inconsistent vital signs monitoring, resulting in hospitalization for septic shock and a urinary tract infection. The facility's policy required daily monitoring for residents receiving skilled services, but this was not followed, as confirmed by the DON.
A resident experienced a delay in receiving appropriate care for a suspected osteomyelitis in the left middle finger, resulting in amputation and hospitalization. The delay was due to inadequate documentation and communication by the Social Services Assistant and lack of follow-up by the Director of Nursing. Medical professionals indicated that timely intervention could have prevented the amputation.
Resident Denied Re-Entry After Appointment Due to Improper AMA Discharge Process
Penalty
Summary
The facility failed to follow its discharge policy for a resident who was not allowed to return after leaving for a doctor's appointment. The resident, who had diagnoses including unspecified dementia, rheumatoid arthritis, cerebrovascular disease, hypertension, amnesia, and alcohol dependence, left the facility for an appointment without a physician's order or proper notification. Upon return, the resident was denied re-entry by staff following instructions from the social services director (SSD), who believed the resident had left against medical advice (AMA). The SSD initiated an AMA form and instructed staff not to allow the resident back, despite there being no physician's order for an AMA discharge. Staff interviews revealed that the nurse on duty did not notify the director of nursing (DON) or the physician about the resident's return and simply followed the SSD's instructions. The certified nursing assistant (CNA) provided the resident with an AMA form when he returned, and the resident expressed that he had nowhere to go. The resident remained outside the facility for at least an hour, during which time his sister contacted the police, who then called paramedics to transport the resident to the hospital. There was no documentation that the physician was notified about the situation, and the DON was only informed the following morning. The facility's policy requires immediate notification of the attending physician or on-call provider and proper documentation when a resident leaves AMA. In this case, these procedures were not followed, as there was no physician notification or order, and the resident was not properly assessed or prepared for a safe transfer or discharge. The emergency department's provider note documented the incident as suspected abandonment, highlighting the lack of adherence to required protocols.
Failure to Document Comprehensive Pressure Ulcer Assessments
Penalty
Summary
The facility failed to provide care and services related to pressure ulcers in accordance with professional standards of practice for one resident. Specifically, the weekly wound assessments for a resident with a chronic, non-healing stage 4 pressure ulcer to the sacrum did not include proper descriptions or measurements of the wound. The assessments lacked documentation of essential wound characteristics such as size, color, drainage, odor, and pain, as required by facility policy. This omission was confirmed through review of the resident's clinical records and interviews with licensed vocational nurses, who acknowledged the absence of these details in the weekly assessments over an extended period. The resident involved was admitted with multiple diagnoses, including chronic systolic congestive heart failure, a stage 4 pressure ulcer of the sacral region, and functional quadriplegia. Observations indicated the resident required total assistance with feeding and was calm and comfortable at the time of the survey. The regional nurse consultant also verified that proper documentation of wound assessments, including all relevant descriptors, was expected but not completed. The facility's policy required comprehensive weekly documentation of wound status, which was not followed in this case.
Failure to Accurately Document Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that controlled substance medications were fully accounted for on the Medication Administration Record (MAR) for three out of six residents reviewed. In multiple instances, nursing staff signed out controlled medications from the Controlled Drug Record (CDR) but did not document the administration of these medications on the MAR. Specifically, for one resident prescribed Butalbital-Acetaminophen-Caffeine for severe migraines, three tablets were signed out in the CDR but not recorded as administered on the MAR on three separate occasions. Another resident with an order for Hydrocodone-Acetaminophen for pain management had one tablet signed out in the CDR without corresponding documentation on the MAR. A third resident receiving Tramadol for pain had two tablets signed out in the CDR that were not documented on the MAR. These discrepancies were verified by the Regional Nurse Consultant (RNC) during concurrent interviews and record reviews, who acknowledged that the medications were not properly accounted for in both the CDR and MAR. The Pharmacy Consultant also confirmed that documentation should occur in both records to prevent medication diversion. The facility's policy requires that the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the MAR and CDR, but this protocol was not followed in the cited cases.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
A medication error rate of 9.68% was identified during medication administration observations, with three errors out of 31 opportunities involving two residents. For one resident with type 2 diabetes and diabetic neuropathic arthropathy, a licensed vocational nurse failed to administer both gabapentin, prescribed for nerve pain, and docusate sodium, prescribed for constipation, at the scheduled 9:00 a.m. medication pass. The nurse later confirmed the omission upon review of the medication administration record and acknowledged the error. In a separate incident, another resident was administered Xarelto 20 mg, an anticoagulant, without food, despite the physician's order specifying it should be taken with dinner. The nurse verified the order required administration with food in the evening, and both the regional nurse consultant and pharmacy consultant confirmed that the medication should be given as ordered and in accordance with manufacturer guidelines. Facility policy also requires medications to be administered as ordered and per manufacturer specifications.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies related to medication storage and labeling within the facility. During inspections of medication carts and storage rooms, expired medications such as Buspirone HCL and Latanoprost eye drops were found in active medication storage. Additionally, two vials of tuberculin purified protein and a bottle of Ciprofloxacin eye drops were discovered without open dates, contrary to facility policy requiring such labeling for multi-use vials and bottles. An unopened vial of Humulin R, which requires refrigeration, was found stored at room temperature, and oral medications were stored together with eye drops in the same drawer, violating segregation protocols. Further observations revealed that one medication cart drawer was unclean, containing a sticky substance, and discontinued medications were stored in active medication carts rather than being removed and secured as per policy. Interviews with nursing staff, the pharmacy consultant, and the regional nurse consultant confirmed these findings and acknowledged that these practices did not align with facility policies or accepted professional standards. The facility's own policies require proper labeling, segregation, and storage of medications, as well as regular inspection and removal of discontinued or expired drugs. No specific residents were identified as directly affected in the report, and the deficiencies were observed through inspection and staff interviews. The findings were based on direct observation of medication storage areas and carts, as well as review of facility policies and staff confirmation of improper practices.
Unsanitary Kitchen Equipment and Improper Storage of Chemicals
Penalty
Summary
Surveyors observed that kitchen equipment, including large tray pans, plate storage containers, stainless racks, plastic pitchers, plastic containers for utensils, and baking pans, had brownish to blackish discoloration and rusty spots. These unsanitary conditions were verified by both the cook and the certified dietary supervisor during multiple observations. The facility's policy requires all kitchen equipment and utensils to be kept clean, maintained in good repair, and free from corrosion, but these standards were not met. Additionally, dishwashing chemicals and garbage containers were found stored beside food items such as flour, pancake flour, mashed potatoes flour, and near utensils and pitchers used for residents. Both the cook and the registered dietitian acknowledged that these chemicals and garbage containers should not have been stored in these locations, as per facility policy, which mandates that poisonous and toxic materials be stored away from food service areas and on shelves used for no other purpose.
Failure to Follow Standardized Recipes for Pureed Diets
Penalty
Summary
The facility failed to ensure that food recipes for pureed diets were followed during food preparation. Specifically, during observations, the cook did not adhere to the standardized recipes for pureed baked beans and deluxe coleslaw by adding thickener to both dishes, despite the recipes not calling for thickener. The cook prepared 36 ounces of each dish, intended for eight residents on pureed diets, and added thickener before setting the food aside at the desired temperature. Review of the facility's recipes confirmed that thickener was not to be added to these items. Interviews with the cook, the certified dietary supervisor, and the registered dietitian confirmed that the recipes were not followed as written. The facility's policy and procedures require that menu items be prepared according to written menus and standardized recipes to preserve or enhance residents' nutrition and hydration status. These failures had the potential to decrease food palatability and, consequently, the amount of food consumed by the eight residents on pureed diets.
Failure to Timely Replace Nasal Cannula for Infection Control
Penalty
Summary
The facility failed to implement proper infection control measures when a resident's nasal cannula, which is used for oxygen administration, was not replaced in accordance with the facility's policy and the resident's physician order. During an observation, it was noted that the nasal cannula in use was dated from a previous week, indicating it had not been changed as required. The resident's order summary specified that the nasal cannula tubing should be changed and dated weekly if in use, and the facility's policy also required weekly changes or as needed if soiled or contaminated. A licensed vocational nurse confirmed that the nasal cannula should have been changed weekly to prevent infection, but this was not done, resulting in non-compliance with infection control protocols.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to ensure that multiple resident rooms met the required minimum of 80 square feet per resident, as observed during the initial pool observation. Specific rooms were identified with less than the required space per resident, including several three-bed rooms with as little as 63.01 to 74.76 square feet per resident, and two-bed rooms with 70.26 and 73.23 square feet per resident. These findings were based on direct measurement and review of room sizes. During the survey, interviews with staff and residents did not reveal any care issues related to the size of the rooms.
Failure to Monitor Vital Signs Leads to Hospitalization
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice by not consistently monitoring vital signs for a resident, which led to an unrecognized decline in the resident's physical and mental status, resulting in hospitalization. The resident, who was admitted with diagnoses including Parkinson's Disease, Spinal Stenosis, and a psychotic disorder, was found to have a critical condition upon hospital admission, including septic shock and a urinary tract infection. The lack of consistent vital signs monitoring was confirmed by the Director of Nursing, who acknowledged that there was no physician order for the resident's vital signs monitoring. The resident's vital signs were inconsistently checked, with records showing only a few instances of monitoring in September and October. The last recorded vital signs were four days before the resident's condition changed, leading to an emergency hospital transfer. Interviews with staff indicated that the resident was non-verbal, totally dependent, and required assistance with feeding. The facility's policy required vital signs to be obtained daily or as ordered by a physician for residents receiving skilled services, but this was not adhered to in the case of this resident.
Delayed Referral Leads to Finger Amputation
Penalty
Summary
The facility failed to provide timely and appropriate treatment for a resident who was suspected of having osteomyelitis in the left middle finger. The resident was initially seen by a wound care doctor who recommended a referral to a hand surgeon on the same day. However, the appointment with the hand surgeon was not scheduled until 33 days later, during which time the resident's condition worsened, leading to the amputation of the left middle finger and hospitalization. The delay in scheduling the appointment was due to several factors, including the Social Services Assistant's failure to document the referral process and communicate effectively with the resident's primary care doctors. The SSA did not inform the doctors of the insurance authorization for the hand surgeon consultation, nor did she seek an earlier appointment with another surgeon. Additionally, the Director of Nursing did not follow up on the referral status during interdisciplinary team meetings, which contributed to the oversight. Interviews with medical professionals involved in the resident's care revealed that the amputation could have been prevented with earlier intervention. The hand surgeon expressed concerns about potential negligence, and the resident's primary care doctor stated that she would have taken immediate action if informed of the x-ray results and referral status. The facility's policies on abuse and neglect and social services referrals were not adequately followed, leading to the deficiency in care.
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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.
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Nursing homes near Morgan Hill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacific Hills Post Acute | 0.2 mi | ★★★★★ | 22 | 0 |
| Gilroy Healthcare Center | 8.7 mi | ★★★★★ | 2 | 0 |
| Manresa Healthcare Center | 15.1 mi | ★★★★★ | 12 | 0 |
| Watsonville Nursing Center | 15.3 mi | ★★★★★ | 12 | 0 |
| Watsonville Post Acute Center | 15.3 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.