Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an
interview and record review, the facility failed to ensure medications were administered as ordered by the
medical doctor (MD) for 1 of 2 sampled Resident (Resident 1). This failure had the potential to adversely
affect the health and well- being of Resident 1.
Findings:
A Record review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick
glance) indicated Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's FS indicated
Resident admitted with diagnoses included dementia (loss of ability to think, remember, and reason to
levels that affect daily life and activities), alcohol abuse (disorder when can't stop drinking even when its
puts health and safety at risk), cognitive communication deficit (condition with trouble reasoning and
making decisions while talking), and encephalopathy (disturbance of brain function).
Review of Resident 1's physician's medication orders indicated divalproex (to treat mental illness) 250 mg
(mg: milligrams, unit of measurement of mass equal to a thousandth of a gram) twice a day ordered on
5/30/2024, trazodone (to treat mental or mood disorders) 100mg daily, ordered on 5/30/2024, and
melatonin (to treat delayed sleep phase and sleep disorders) 3 milligrams at bedtime every day, ordered on
5/21/2024.
Review of Resident 1's electronic medication administration record (EMAR: a legal document for
medication administration record) for June 2024 indicated:
Blank EMAR documentation on 6/7/2024, 6/13/2024, 6/15/2024, 6/17/2024, 6/19/2024, 6/22/2024 and
6/23/2024 for administration of divalproex at 4:00 p.m.
Blank EMAR documentation on 6/6/2024, 6/7/2024, 6/13/2024, 6/17/2024, 6/18/2024, 6/19/2024,
6/22/2024, and 6/23/2024 for administration of trazodone and melatonin at 9:00 p.m.
During a concurrent review of EMAR for June 2024 for Resident 1 and interview with registered nurse
supervisor (RN S) on 6/24/2024 at 3:31 p.m., RN S confirmed blank EMAR for above three medications
and dates indicated above. RN S stated if EMAR left blank without license nurse's initial that means
medications were not administered to resident 1. RN S further stated licensed nurses should have
administered and documented EMAR for medications as ordered for Resident 1.
During an interview with director of nursing (DON) on 6/24/2024 at 3:39 p.m., DON confirmed
(continued on next page)
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
555831
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555831
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Herman Health Care Center
2295 Plummer Avenue
San Jose, CA 95125
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
licensed nurses did not administer medications as ordered for Residents 1. DON stated if license nurse did
not initial after administered medications indicated medications were not given to Resident 1. DON further
stated licensed nurses should have administered medications as ordered and completed EMAR
documentation for Resident 1.
Review of facility's P&P titled, Administering Medications, revised December 2012, the P&P indicated,
Medications must be administered in according with orders, including nay required time frame. The
individual administering the medication must initial the resident's MAR (medication administration record)
on the appropriate line after giving each medication and before administering the next ones.
Event ID:
Facility ID:
555831
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555831
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Herman Health Care Center
2295 Plummer Avenue
San Jose, CA 95125
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
Based on interview, and record review, the facility failed to ensure to follow psychiatric nurse practitioner
(PNP: licensed as nurse practitioner or clinical nurse specialist, provides the full range of mental health care
needs)'s recommendations and medication regimen review (MRR: a thorough evaluation of medication
regimen for resident with the goal of promoting positive outcomes) for 2 of 2 sampled Residents (Resident
1 and 2) when;
1. Failed to follow up for PNP's recommendations for medication, and blood tests (common tests healthcare
providers use to monitor overall health or help diagnose medical condition) for Resident 1;
2. Failed to follow up for MRR request for Resident 1; and
3. Failed to follow up for psychologist (a trained mental health professional who specializes in the study and
treatment of mind and behavioral disorders)'s recommendations for Resident 2.
These failures had the potential to effect on health and psychosocial well-being for Resident 1 and 2.
Findings:
Review of Resident 1's face sheet (FS: a document that gives a resident's information at a quick glance)
indicated Resident 1 was admitted to facility on 5/21/2024. Review of Resident 1's FS indicated Resident
admitted with diagnoses included dementia (loss of ability to think, remember, and reason to levels that
affect daily life and activities), alcohol abuse (disorder when can't stop drinking even when its puts health
and safety at risk), cognitive communication deficit (condition with trouble reasoning and making decisions
while talking), and encephalopathy (disturbance of brain function).
1. Review of PNP's recommendations dated 6/11/2024, indicated, risperidone (antipsychotic medication to
treat mental health disorders) 0.25 mg (milligram: a unit of mass equal to one thousandth of a gram) BID
(twice a day) and labs for TSH (thyroid stimulating hormone, a chemical produced by gland in the brain),
CBC (complete blood work: a test, used to diagnose and monitor numerous diseases), CMP
(comprehensive metabolic panel: a blood test that gives body's fluid balance), valproic acid (medication to
used to treat mental disorders] level in blood) level (blood test to measure valproic acid level), and ammonia
(a toxic waste product made by the body during digestion) level (blood test to measure ammonia level in
blood) signed and undated by MD (medical doctor) for Resident 1.
2.Review of offsite medication review form dated 6/16/2024 for Resident 1 indicated facility sent MRR
request for Behavioral changes-unusual behavior patterns, to facility's consulting pharmacy (delivering
medications and providing pharmacy services to facility) via fax (send or receive documents electronically).
Review of clinical documentation for Resident 1 indicated there was no documented evidence for approved
PNP's recommendations for medication and blood work have been ordered for Resident 1.
Review of clinical documentation for Resident 1indicated there was no documented evidence of facility
received MRR request response from consulting pharmacist or facility followed up for response for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555831
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555831
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Herman Health Care Center
2295 Plummer Avenue
San Jose, CA 95125
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
MRR for Resident 1.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 2's FS indicated Resident 1 was admitted to facility on 4/30/2024. Resident 2's FS also
indicated Resident 2's admission diagnoses included alzeimer's disease (a progressive disease that
destroys memory and other important mental functions).
Residents Affected - Few
Review of Resident 2's psychologist notes dated 6/19/2024 indicated, Consider Follow-up by Psychiatry (a
branch of medicine concerned with study, diagnosis, and treatment of mental illness).
Review of Resident 2's clinical documentation indicated there was no documented evidence for psychiatry
follow up for Resident 2.
During an interview with registered nurse supervisor (RN S) on 7/24/2024 at 3:09 p.m., RN S confirmed
PNP's recommendations for medication and blood work were not ordered for Resident 1. RN S also
confirmed MRR not been followed up for Resident 1 after requested on 6/16/2024. RN S acknowledged
psychologist recommendations not been followed up for Resident 2. RN S stated nursing staff should have
followed PNP's recommendations and MRR response from pharmacy for Resident 1. RN S also stated
nursing staff should have followed up with psychiatry for Resident 2.
During an interview with facility's director of nursing (DON) on 7/24/2024 at 3:39 p.m., DON acknowledged
nursing staff did not follow PNP's recommendations and requested MRR response from pharmacy for
Resident 1. DON also acknowledged psychologist recommendations for psychiatry not been followed for
Resident 2. DON stated nursing staff should have carried over MD approved PNP's recommendations for
medication and blood work for Resident 1. DON also stated nursing staff should have followed up with
pharmacy for MRR response for Resident 1 and followed up with psychiatry for Resident 2.
Review of facility's policy and procedure (P&P) titled, Physician Services, revised February 2021, the P&P
indicated, Physician orders and progress notes are maintained in accordance with facility policy.
Consultative services are made available from community-based consultants or from a local hospital or
medical center.
Review of facility's P&P Medication Utilization and Prescribing- Clinical Protocol, revised April 2018, the
P&P indicated, The consultant pharmacist can help by reviewing facility medication usage patterns and
trends and by intensifying medication reviews of individuals taking medications that present clinically
significant risks.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555831
If continuation sheet
Page 4 of 4
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
FAQ · About this visit
Common questions about this visit
What happened during the July 25, 2024 survey of HERMAN HEALTH CARE CENTER?
This was a inspection survey of HERMAN HEALTH CARE CENTER on July 25, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HERMAN HEALTH CARE CENTER on July 25, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.