Gilroy Healthcare Center

In the surveyor’s words

From the most serious findings on record at Gilroy Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF757Jun 23, 2025

  Based on interview, and record review , the facility failed to ensure 67 out of 67 residents (residents who received Levaquin [a brand name for levofloxacin, a type of antibiotic known as fluoroquinolone used to treat bacterial infections] and Metformin [a medication that helps control the amount of glucose (sugar) in the blood]) (Residents 392, 389, 122, 130, 127, 124, 383, 393, 132, 83, 126, 391, 125, 129, 388, 68, 7, 10, 82, 52, 41, 394, 123, 390, 70, 384, 21, 387, 133, 93, 74, 385, 326, 381, 103, 47, 377, 222, 89, 49, 46, 106, 131, 323, 16, 22, 33, 63, 50, 23, 386, 128, 111, 322, 4, 71, 80, 99, 15, 382, 2, 64, 26, 17, 380, 90, and 65) were free from unnecessary medications when there was inadequate monitoring and systemic failure in management of residents on medications with black box… […]

• Actual harm, isolatedF689Apr 14, 2023

  Based on interview, and record review, the facility failed to provide assistance and supervision for one of three sampled residents (Resident 1). The facility failed to implement the self- care deficit care plan when certified nursing assistant C (CNA C) did not assist Resident 1 during toileting and left Resident 1 unsupervised inside the resident restroom. This failure resulted to Resident 1's fall with right intertrochanteric (hip) fracture and a decline in toilet use. Findings: Review of Resident 1's face sheet (a document that gives a resident's information) indicated, Resident 1 was admitted on ,d+[DATE] with diagnoses including fracture (broken) of right pubis (pubic bone, one of the three sections of the hipbone, together these two bones form the front of the pelvis), syncope… […]

• No harm, potential for more than minimal, widespreadF880Apr 23, 2021

  Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Glucometer was not disinfected after a resident use; 2. Licensed nurse (LN) H did not wear his facemask while talking to another staff; 3. LN F did not remove gloves prior to entering a resident room; 4. Three staff did not perform hand hygiene in between tasks; 5. Physician did not change gown in between residents in the observation unit; 6. Urinal was observe hanging in a trash can; 7. Resident 109's urinary catheter tubing was touching the floor; 8. Three oxygen filters were dirty. These failures could result in the spread of infection and cross-contamination. Findings: 1. […]

• No harm, potential for more than minimal, patternF658Jun 24, 2026

  Based on interview and record review, the facility failed to ensure to provide care and services to meet professional standards for one of three sampled resident (Resident 1) when license nursing staff failed to follow medical doctor's (MD, a licensed healthcare professional who practices medicine to diagnose, treat, and prevent illnesses, injuries, and other medical conditions for residents) order to notify the MD when Resident 1's blood glucose (BG, sugar level in blood) level were more than 300 (mg/dl, milligrams per deciliter, standard unit of measuring BG) for 14 times across nine days in two months.These failures had the potential to affect plan of care, medical condition and well-being for Resident 1. […]

• No harm, potential for more than minimal, patternF757Jun 24, 2026

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary medication. Resident 1 received insulin (a man- made medication used to treat high blood glucose [BG, sugar in blood] level) without documented evidence of adequate monitoring for signs and symptoms (s/s) of hypoglycemia (a medical condition with blood glucose drops to dangerous low levels) and hyperglycemia (a medical condition with high blood glucose level) on routine basis for Resident 1. These failures had the potential to affect health condition, well-being and necessary use of insulin for Resident 1. […]