555831
12/29/2025
Herman Health Care Center
2295 Plummer Avenue San Jose, CA 95125
F 0605
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Based on interview and record review, the facility failed to ensure free from unnecessary antipsychotic medications (medications capable of affecting the minds, emotions, behaviors, and health conditions) for one of three sampled residents (Resident 1 and 2) when:There was no documented evidence of non-pharmacological (treatments and strategies that to manage health conditions without using antipsychotic medications) approaches attempted before administered antipsychotic medication to Resident 1 and 2.This failure had the potential to place above sampled residents at risk to receive unnecessary antipsychotic medications.Findings:Review of Resident 1's face sheet (FS: a document that gives a resident's information at a glance) indicated Resident 1 was admitted to facility on 5/14/2024 and was discharged from facility on 7/18/2025.Review of Resident 1's diagnoses included cerebral infarction (condition occurs when loss of blood flow to brain happens) and agitation (state of extreme restlessness and mental distressReview of Resident 1's order summary report indicated, an order for quetiapine (antipsychotic medication used to treat various mental health conditions) 100 MG (milligrams, a unit of mass or weight, equal to one thousandth of a gram) at bed time, dated 8/12/2024 and this order was discontinued on 2/21/2025.Review of Resident 1's electronic medication administration record (EMAR, a digital system used in healthcare settings to track and document the administration of medications to residents) for December 2024, January 2025, and February 2025 indicated, Resident 1 received medication quetiapine 100 MG at 9:00 p.m. everyday. Further review of Resident 1's clinical documentation indicated, there was no documented evidence of facility attempted non-drug approaches before administered this antipsychotic medication to Resident 1.During a concurrent record review of Resident 1's order summary report and EMAR for medication quetiapine and interview with facility's director of nursing (DON) on 12/29/2025 at 3:45 p.m., DON confirmed quetiapine order and administration during above three months for Resident 1. DON also confirmed there was no documented evidence of non-drug interventions attempted before administered this antipsychotic medication to Resident 1. DON stated license staff should have attempted non-drug approaches before given quetiapine to minimize the need or allow the lowest possible dose for this resident.Review of Resident 2's FS indicated Resident 2 was admitted to facility on 7/11/2024 and was discharged from facility on 11/25/2025.Review of Resident 2's diagnoses included dementia (condition that interfere with daily living, memory, thinking, problem solving and language abilities), depression (mood disorder with persistent feelings of sadness, hopelessness, and loss of interest in active daily living situations), and adjustment disorder (a mental health condition that causes struggle to cope with changes in daily life).Review of Resident 2's order summary report indicated, an order for quetiapine 75 MG at bed time, dated 8/22/2025.Review of Resident 2's EMAR for September 2025, October 2025, and November 2025 indicated Resident 2 received medication quetiapine 75 MG at 9:00 p.m. everyday. Further review of Resident 2's clinical documentation indicated, there was no documented evidence of facility attempted non-drug approaches before administered this antipsychotic medication to
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555831
555831
12/29/2025
Herman Health Care Center
2295 Plummer Avenue San Jose, CA 95125
F 0605
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Resident 2.During a concurrent record review of Resident 2's order summary report and EMAR for medication quetiapine and interview with facility's director of nursing (DON) on 12/29/2025 at 3:45 p.m., DON confirmed quetiapine order and administration for above three months for Resident 2. DON also confirmed there was no documented evidence of non-drug interventions attempted before administered this antipsychotic medication to Resident 2. DON stated license staff should have attempted non-drug approaches before given quetiapine to minimize the need or allow the lowest possible dose for this resident.Review of facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, revised July 2022, the P&P indicated, Pertinent non-pharmacological interventions must be attempted. For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms are: not sufficiently relieved by non-pharmacological interventions;
555831
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