Gateway Transitional Care Center

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility failed to assess the risks of transporting residents backwards in Geri-Chairs and had not provided attentive care during resident transports in Geri-Chairs. This was true for 1 of 2 residents (Resident #12) who was observed during transport down the facility's C-Hallway. This deficient practice placed residents at risk for harm when improperly transported and supervision was not provided.

Inspectors wroteBased on policy review, observation, record review, and interviews, it was determined the facility failed to a) provide respiratory services as ordered by the physician and b) ensure physician orders and resident care plans identified interventions for oxygen therapy. This was true for 5 of 13 residents (#3, #5, #9, #28, and #59) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure residents were assessed to determine if they were safe to self-administer medications for 1 of 6 residents (Resident #83) reviewed for self-administration of medications. This failure created the potential for adverse effects if residents self-administered medications inappropriately.

Inspectors wroteBased on observation, policy review, record review, and resident and staff interview, it was determined the facility failed to ensure resident's call light device in their room was within reach for 2 of 19 Residents (#42 and #84) whose rooms was observed. This deficient practice had the potential to cause harm if residents experienced falls, accidents, or had other needs and could not reach the call light device.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflect resident's status. This was true for 1 of 19 residents (Resident #47 ) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and/or monitored due to inaccurate assessments.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to include a resident's mental and psychosocial needs in their Baseline Care Plan. This was true for for 1 of 19 residents reviewed for baseline care plans (Resident #47).

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 5 of 19 residents (#3, #28, #47, #59, #82) whose care plans were reviewed. This placed resident at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed.

Inspectors wroteBased on facility standing orders, record review, and staff interview, it was determined the facility failed to follow a) facility bowel care standing order of delivering specific medications to residents who have not had a BM due to constipation for 1 of 1 resident (#28) whose record was reviewed for bowel care and b) obtain a physician's order for insertion of an IV and dressing changes. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's standing order and potential harm if a resident had an IV inserted without consulting the physician.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure nursing staff removed meal trays from resident rooms in a timely manner for which they had the knowledge, skills, and competencies. This was true for 1 of 1 resident (Resident #28) whose breakfast meal tray was observed in her room prior to lunch. This had the potential to create dissatisfaction with meals and decrease residents' quality of life.

Inspectors wroteBased on review of the State Operations Manual, Appendix PP, staffing schedules, personnel files, and staff interviews, it was determined the facility failed to ensure full-time employees working as a nurse aide successfully completed a State approved training and competency evaluation program within 4 months of being hired. This was true for 4 of 10 nurse aides whose personnel files were reviewed. This failure had the potential to result in negative outcomes for all residents living in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders without errors for 1 of 6 residents (Resident #68) observed to receive medication during the survey. This had the potential to affect the resident's health if she did not receive the medications that were ordered. This resulted in a facility medication error rate of 6.9%. Resident #68 was admitted to the facility on [DATE], with multiple diagnoses including fractured left humerus (long bone in the upper arm) and diabetes. Resident #68's physician order dated 6/13/25, documented Cranberry Oral Tablet. Give 500 mg by mouth one time a day for supplement. Resident #68's physician order dated 6/13/25, documented Multivitamin Oral Tablet. Give 1 tablet by mouth one time a day for supplement. [...]

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure stored medications had not passed their expiration date and ensure medication carts were kept locked when not attended by authorized staff in an area where residents could access it. These failed practices affected a) 1 of 3 medication storage rooms creating the potential for residents to receive expired medications with decreased efficacy and b) 1 of 4 medication carts which had the potential for residents to gain access and ingest medications that can cause significant adverse outcomes.

Inspectors wroteBased on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to ensure food items were dated, labeled, and stored at a safe temperature. These deficient practices had the potential to impact all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on observation, interview, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not store oxygen supplies in a sanitary manner. This was true for 4 of 9 Residents (#5, #47, #72, and #84). These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure the kitchen was maintained in a sanitary manner when sanitizer solutions were had inadequate strength, rust was observed on the inside of the ice machine, and the dishwashing area contained caulking that was peeling off with food particles entrapped creating a surface that was uncleanable on the stainless counter. These deficiencies had the potential to affect all 76 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on observation, policy review, record review, and staff interview, the facility failed to ensure the required nursing staff posting accurately reflected the actual staff hours to care for the 76 current residents and failed to ensure the posting included an updated census for each shift. This failure had the potential to inaccurately inform any resident, family member, or visitor to the facility of the available nursing staff caring for residents.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 2 of 2 residents (#10 and #24) reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time.

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 1 of 19 residents (Resident #39) reviewed for accuracy of MDS assessments. This deficiency created the potential for residents to not have their care needs met due to inaccurate assessments.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 1 of 4 residents (Resident #33) reviewed for quality of care. This created the potential for Resident #33 to have decreased caloric intake and weight loss when physician's orders were not followed to provide a specific dietary supplement.

Inspectors wroteBased on policy review, record review, facility fall reports, observation, and staff interview, the facility failed to ensure residents were adequately supervised and had interventions in place to prevent falls. This was true for 2 of 6 residents (#22 and #67) reviewed for falls. The failure to implement adequate supervision and interventions created the potential for Resident #22 and Resident #67 to sustain significant injuries from falls.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure a resident received oxygen therapy per physician's orders. This was true for 1 of 1 resident (Resident #39) reviewed for oxygen therapy. This failure created the potential for Resident #14 to experience hyperoxia (cells, tissues, and organs are exposed to an excess supply of oxygen.

Inspectors wroteBased on policy review, record review, observation, and staff interview, it was determined the facility failed to ensure that prior to the placement of bed rails, alternatives to bed rails were attempted and individual residents were thoroughly assessed for the risk of entrapment. This was true for 1 of 2 residents (Resident #31) reviewed for bed rails. This failure created the potential for harm due to the risk for injury, entrapment and/or death due to lack of opportunity for the resident and/or their representative to make an informed decision regarding the use of bed rails.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure the medical necessity of psychotropic medication administration. This was true for 1 of 6 residents (Resident #7) reviewed for psychotropic medication administration. This failure created the potential for Resident #7 to experience negative side effects related to receiving more psychotropic medication than necessary.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled and had not expired. This was true for 2 of 5 insulin pends in a medication cart. This failure created the potential for insulin pens to be used for different residents presenting a risk for cross-contamination or to receive expired medications with decreased efficacy for blood glucose levels.

Inspectors wroteBased on record review, observation, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 3 of 19 residents (#10, #163, and #182) observed for infection control. These failures put residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure beds and bed rails were inspected and maintained as part of an ongoing program. This was true for 2 of 6 residents (#10 and #22) reviewed for bed rails. This failure created the potential for injury or harm if a resident was to become entrapped by unmonitored equipment.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to a) date items in the freezer and refrigerator, b) ensure staff contained all hair with a hair net, c) ensure infection control practices were implemented when gathering ice to be used to keep foods cool and d) clean and maintain the kitchen floor. These deficient practices placed 18 of 18 sample residents (#1, #2, #11, #22, #23, #26, #27, #36, #42, #43, #44, #62, #65, #67, #71, #76, #228, and #229) who dined in the facility, and the other 61 residents who dined in the facility, at risk food borne illness or other disease-causing pathogens.

Inspectors wroteBased on Resident Council meeting minutes, Resident Group interview, policy review, and staff interview, it was determined the facility failed to address Resident Council concerns. This was true for 8 of 8 residents (#3, #8, #17, #26, #36, #45, #60, and #64) who participated in the Resident Group interview. The deficient practice had the potential to cause psychosocial harm for residents frustrated by the perception their concerns were not valued or addressed by the facility.

Inspectors wroteBased on observation, policy review, review of Resident Council minutes, resident interview, Resident Group interview, test tray evaluation, and staff interview, it was determined the facility failed to ensure palatable food was served. This was true for 15 of 18 residents (#1, #3, #8, #17, #20, #26, #27, #36, #38, #41, #45, #53, #54, #60, and #64) reviewed for food and nutrition. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to implement appropriate infection control practices when assisting residents during dining and after a Hoyer lift transfer of a resident on contact precautions. This was true for 2 of 6 residents (#33 and #42) observed in the assisted dining room and 1 of 4 residents (Resident #16) in contact precaution rooms. These deficient practices created the potential for harm by exposing residents to the risk of infection and cross contamination.

Inspectors wroteBased on record review, policy review, resident, resident representative, and staff interview, it was determined the facility failed to document, investigate, and report complaints expressed by 1 of 19 residents (Resident #227) whose complaints were reviewed. This failure created the potential for harm if residents' verbal grievances were not acted upon and residents did not receive appropriate care or were at risk for abuse or neglect.

Inspectors wroteBased on record review, policy review, resident interview, and staff interview, it was determined the facility failed to ensure residents' care plans were revised as needed. This was true for 1 of 21 residents (Resident #67) whose care plans were reviewed. This failure had the potential for harm if cares and/or services were not provided due to inaccurate information.

Inspectors wroteBased on policy review, record review, and staff and resident interview, it was determined the facility failed to ensure residents were offered the pneumococcal vaccine and information and education consistent with current Centers for Disease Control and Prevention recommendations. This was true for 1 of 7 residents (Resident #23) reviewed for pneumococcal immunizations. This failure created the potential for harm to residents should they acquire, transmit, or experience complications from pneumococcal pneumonia.