Other·March 30, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a complaint conducted on 3/23/18. For Complaint CA00573976 regarding Quality of Care/Treatment, a federal deficiency was identified (see F684). The deficiency had a scope and severity of "G". A Class "B" Citation was also issued. Inspection was limited to the specific compliant investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 25460, Health Facilities Evaluator Nurse.

F684 SS=G Quality of Care CFR(s): 483.25

F684 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I1PD11 Facility ID: CA070000040 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055797 (X3) DATE SURVEY COMPLETED 03/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GILROY HEALTHCARE CENTER 8170 Murray Ave Gilroy, CA 95020 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review, the facility failed to meet the needs of one of three sampled residents (Resident 1) when his low laboratory result for Dilantin (medication for seizure) level was not followed through so the results were not communicated to the physician. This failure resulted in Resident 1 sustaining a seizure episode and was sent to the acute care hospital. Findings: Resident 1's Admission Record indicated he was admitted on 5/16/12 with diagnoses including epilepsy (epilepsy is a brain disorder that causes people to have recurring seizures). During an observation on 2/27/18 at 10:00 a.m., Resident 1 was in his wheelchair, propelling himself in the hallway. Resident 1 did not respond when greeted. Review of Resident 1's clinical record indicated a physician's order dated 11/4/17 for a repeat Dilantin level due to low Dilantin level on 11/1/17 of 4.1 ug/ml (ug/m/- microgram per milliliter- a measurement of dilantin blood concentration). Review of Resident 1's Laboratory Requisition Sheet dated 11/16/17 indicated laboratory blood tests including Dilantin level blood samples were drawn and collected. The laboratory results were received through facsimile report on the same day but the results did not include the Dilantin level. During an interview on 2/27/18 at 1:15 p.m., the health information manager (HMI) stated on 11/16/17, Resident 1's laboratory results were received through facsimile report from the laboratory facility. She stated she and the licensed nurse "overlooked" that the Dilantin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I1PD11 Facility ID: CA070000040 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055797 (X3) DATE SURVEY COMPLETED 03/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GILROY HEALTHCARE CENTER 8170 Murray Ave Gilroy, CA 95020 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE level result was included in that report. She stated on 2/13/18, the director of nursing (DON) conducted a chart audit, and noted the Dilantin level result was not kept in the resident's medical record. HMI stated she called the laboratory facility and requested for Dilantin level report. The report revealed a low Dilantin level of 0.9 ug/ml. The laboratory report indicated the normal range was 10.020.0ug/ml. HMI acknowledged she and the licensed nurse did not review and followed through on 11/16/17 when they received the incomplete laboratory report. During a concurrent interview with the DON, she confirmed the licensed nurse and the HMI overlooked the result of the Dilantin level. Review of Resident 1's nursing progress notes dated 1/26/18 indicated Resident 1 was sent to the acute care hospital through 911 paramedics due to an episode of seizure. The emergency room's laboratory report indicated he had a low Dilantin level of less than 5.6 ug/ml. The report indicated the normal range was 15.0-20.0 ug/ml. Review of Resident 1's acute care records dated 1/26/18 indicated the paramedics witnessed 2 episodes of body seizures during the transport. Both episodes were tonoclonic seizures lasting for 2 minutes and the other one lasting for about 30 seconds. Review of Resident 1's acute care discharge summary dated 1/26/18 indicated status epilepticus with subtherapeutic dilantin level. During an interview on 2/27/18 at 2:25 p.m., the primary care physician (PCP) indicated on 2/13/18 he was informed and made aware of the incident on 1/26/18. He stated on 11/16/17, the facility did not get Resident 1's Dilantin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I1PD11 Facility ID: CA070000040 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055797 (X3) DATE SURVEY COMPLETED 03/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GILROY HEALTHCARE CENTER 8170 Murray Ave Gilroy, CA 95020 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE level report from the laboratory, so he was not aware of the low Dilantin level result. PCP stated "subsequently [Resident 1] had a seizure" episode and was taken to an acute care hospital where Resident 1 was treated for low Dilantin level and returned to the facility on the same day. Review of Resident 1's physician's progress notes dated 2/27/18 indicated Resident 1 had laboratory test done 11/16/17 for Dilantin level but he never got the result and was not aware of the low Dilantin level of 0.9 ug/ml. This resulted in Resident 1 having a seizure and was taken to the emergency department on 1/26/18. The facility's undated policy and procedure on "LTC Health Information Practice and Documentation Guidelines" indicated: "A report of findings for all laboratory, radiology or special diagnostic services must be retained in the medical record. When a report is received, a nurse must review the results, note the findings, initial and date the report and make an entry in the medical record. The physician must be promptly notified of results of laboratory findings..." Review of Lexi-Comp (a clinical drug information resource) indicated Dilantin (phenytoin) "dosage should be individualized to provide maximum benefit. In some cases serum blood level determinations may be necessary for optimal dosage adjustments-the clinically effective serum level is usually 10-20 mcg/mL. 50% of patients show decreased frequency of seizures at concentrations >10 mg/L (SI: >40 micromole/L)". Review of an article dated 3/23/18 at Lab test online website, (https://labtestsonline.org/tests/phenytoin) also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I1PD11 Facility ID: CA070000040 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055797 (X3) DATE SURVEY COMPLETED 03/23/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GILROY HEALTHCARE CENTER 8170 Murray Ave Gilroy, CA 95020 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated "the level of phenytoin in the blood must be maintained within a narrow therapeutic range. If levels are too low, the affected person may experience seizures: if they are too high, the person may experience symptoms associated with phenytoin toxicity. These may include loss of balance and falling, involuntary eye movement from side to side (nystagmus), confusion, slurred speech, tremors, and low blood pressure". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: I1PD11 Facility ID: CA070000040 If continuation sheet 5 of 5