Gino J Merli Veterans Center

In the surveyor’s words

From the most serious findings on record at Gino J Merli Veterans Center, in the surveyor’s own words.

• Actual harm, isolatedF689May 13, 2025

  Based on observations, a review of clinical records, select facility policies, documentation provided by the facility, and resident and staff interviews, it was determined that the facility failed to adequately assess a resident's safety needs and implement adequate safety measures for a resident identified as at risk for falls, including a fall with multiple abrasions and a cervical spine fracture for one out of three residents sampled (Resident 1) which caused actual harm. Findings include: A review of the facility policy titled Fall Prevention Program, last reviewed by the facility June 4, 2024, revealed it is the policy of the facility to assist in fall management and prevention, reducing the risk of serious injury from falls while in conjunction optimizing each resident's freedom of… […]

• Actual harm, isolatedF600Dec 3, 2021

  Based on review of the facility's abuse prohibition policy, select investigative reports and clinical records, and staff interview, it was determined that the facility failed to ensure that four residents (Resident 48, Resident 22, Resident 122 , Resident 17 ) were free from physical and/or verbal abuse, which resulted in physical injuries, a fractured finger, lacerations and contusion to one resident (Resident 22) out of 26 sampled residents Findings include: Review of facility policy titled Freedom from Abuse, Neglect, Exploitation, and Misappropriation of Resident Property that was last reviewed by the facility November 15, 2021, revealed that the facility will provide protections for the health, welfare, and rights of each resident residing in the facility. […]

• No harm, potential for more than minimal, patternF757Jun 6, 2025

  Based on clinical record review, facility policy review, resident observation, and staff interviews, it was determined that the facility failed to ensure residents' drug regimens were free from unnecessary medications by administering duplicate antipsychotic therapy without documented clinical justification, and by failing to attempt gradual dose reductions where appropriate, for two residents (Residents 9 and 38). Findings include: A review of the facility policy titled Behavior Management Program, last reviewed in September 2024, revealed that the facility recognizes the importance of ensuring each resident's drug regimen is free from unnecessary medications. Accordingly, the interdisciplinary team will evaluate the resident's response to psychotropic medications on an ongoing basis. […]

• No harm, potential for more than minimal, patternF656Aug 16, 2024

  Based on clinical record review and staff interview, it was determined that the facility failed to include the resident's discharge planning in the comprehensive care plan of four residents out of 35 reviewed (Residents 6, 150, 11, 107). Findings include: A review of the clinical record revealed Resident 6 was admitted to the facility April 3, 2019, with a diagnosis to include Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), diabetes )(body has trouble controlling blood sugar and using it for energy), and acquired absence of the right leg, above the knee (right lower leg amputation). […]

• No harm, potential for more than minimal, patternF690Sep 1, 2023

  Based on a review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to thoroughly assess and evaluate bowel function and implement individualized approaches to restore normal bowel function and fecal continence to the extent possible for two out of 32 sampled residents (Resident 9 and 114). Findings include: A review of facility policy entitled Bowel and Bladder Management Program last reviewed on June 26, 2023, indicated the facility will assist the residents in maintaining their highest practicable level of independence and dignity. Further it is indicated all residents' bowel and bladder habits will be patterned for three days to establish potential patterns on admission and with a change in their bowel and bladder patterns. […]