Gil-Mor Manor

Inspectors wroteBased on observation, interview, and document review the facility failed to revise the care plan with fall interventions following falls for 1 of 3 residents (R3) reviewed for falls.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess falls for root cause, implement appropriate interventions and implement/revise the care plan to prevent and/or reduce the risk of falls for 1 of 3 residents (R3) reviewed for falls.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure Enhanced Barrier Precautions (EBP)- (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities), were implemented or followed during a transfer to reduce the risk of infection to others for 1 of 1 resident (R3).

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure emergency medications stored in 1 of 1 medication storage room were not expired.

Inspectors wroteBased on interview and document review, the facility failed to have a thorough, ongoing infection control surveillance program that included resolution of symptoms and/or if any transmission-based precautions (TBP) had been implemented during 3 of 3 months reviewed (April, May, and June of 2025). The facility also failed to identify when employees would be able to return to work after having signs and symptoms of potential Norovirus for 8 of 8 staff (Cook-A, nursing aide (NA)-A, Cook-B, dietary (aide)-A, trained medication aide (TMA)-A, the infection preventionist (IP), NA-B, and TMA-B) reviewed for January of 2025.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 1 infection control preventionist (IP) had provided oversight of the infection control program and the antibiotic stewardship program.

Inspectors wroteBased on interview and document review the facility failed to ensure 1 of 5 residents (R1) had a Consent for Psychotropic Medication Use identifying the risks, benefits, and alternative treatments available.

Inspectors wroteBased on interview and document review the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) CMS-10055 for 1 of 3 residents (R6) reviewed.

Inspectors wroteBased on interview and document review the facility failed to have 2 of 6 residents (R4, R11) assessed by a physician for need to continue taking an as needed antianxiety medication.

Inspectors wroteBase on interview and document review, the consulting pharmacist (RPh) failed to identify irregularities for 3 of 8 sampled residents (R4, R11, and R28) reviewed.

Inspectors wroteBased on interview and record review the facility failed to assess the need for continued use of an antibiotic for 1 of 5 sampled residents (R28) reviewed for antibiotic use.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure 1 of 1 emergency kit had been secured to avoid the potential for drug diversion.

Inspectors wroteBased on interview and document review, the facility failed to complete a comprehensive assessment for continued use of antibiotics for 2 of 3 (R1 and R17) sampled residents reviewed for antibiotic stewardship.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all 20 nurse aides (NA)-A, NA-B, NA-C, NA-D, NA-E, NA-F, NA-G, NA-H, NA-I, NA-J, NA-K, NA-L, NA-M, NA-N, NA-O, NA-P, NA-Q, NA-R, NA-S, and NA-T), and all 3 trained medication aides/NA's ((TMA)-A, TMA-B, and TMA-C) of 37 total nursing staff, were appropriately trained to manufacturer's instructions for the cleaning and disinfection of 1 of 1 whirlpool tub. This had the ability to affect residents who utilized the whirlpool tub for bathing.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate and/or complete data for staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 2), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 2 of 2 staff (nurse aide (NA)-C and NA-D) appropriately cleaned and disinfected 1 of 1 whirlpool tub according to manufacturers guidelines and failed to provide baseline screenings and/and or testing for 2 of 5 sampled staff (NA-A and trained medication aide (TMA)-B) and 3 of 5 sampled residents (R4, R17, and R11) for tuberculosis (TB) prevention and identification.

Inspectors wroteThe facility failed to comprehensively assess 1 of 1 resident (R15) annually, quarterly, and as needed for risk of elopement and need for a wander guard device when R15 went outside to sit on the patio and subsequently eloped off campus, across a busy highway and into a field where farmers with combines were working.

Inspectors wroteThe facility failed to acquire a physicians order prior to discontinuing a WanderGuard device for 1 of 1 resident (R15) who eloped, had a WanderGuard ordered to be implemented by staff, and was discontinued without a physician order or knowledge the next day.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R15) with a history of elopement was appropriately assessed and supervised when R15 went outside to sit on the patio and subsequently eloped off campus, across a busy highway and into a field where farmers with combines were working. Furthermore, the facility failed to ensure 1 of 1 WanderGuard system remained active on the [NAME] wing at all times.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff had not stored in-use medication with expired medication in 1 of 1 narcotic medication box and ensure that expired medication was not administered to 1 of 1 resident (R3).

Inspectors wroteBased on interview and document review, the facility failed to ensure data submitted to the Quality Assurance and Performance Improvement (QAPI) committee was analyzed and documented to ensure areas identified had oversight for their perspective outcomes brought forth. This had the potential to affect all 31 residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow Centers for Disease Control (CDC) guidance for COVID-19 when 1 of 1 facility employee had a positive COVID-19 test on 7/31/23 and was allowed entry into the building 8/1/23 to retest at the facility. The facility also failed to implement transmission-based precautions (TBP) for 1 of 1 resident (R29) who exhibited potential signs and symptoms (S/S) of COVID-19. The facility also failed to test all remaining residents and staff per CDC guidelines after determining current outbreak status. In addition, the facility also failed to have COVID-19 risk assessment to identify the probability of occurrence, level of harm, and any impact on care related to current or future outbreaks in the facility and their response to mitigate potential or actual outbreak of COVID-19. [...]

Inspectors wroteBased on interview and document review, the facility failed to provide mandatory training on the facility's Quality Assurance/Assessment and Performance Improvement Plan (QAPI) that included the goals and various elements of the program or how the facility intended to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure alcoholic beverages were secure in 1 of 1 activity refrigerators this had the potential to affect 16 of 31 residents with Alzheimer's/Dementia and/or potential wandering behaviors (R1, R7, R8, R9, R10, R11, R12, R13, R14, R15, R19, R20, R21, R22, R27 and R29).

Inspectors wroteBased on interview and document review, the facility failed to ensure 5 of 5 sampled residents (R2, R21, R29, R30 and R134) were appropriately vaccinated against pneumococcal disease by offering updated PCV-15 or PCV-20 vaccination per Centers for Disease Control (CDC) vaccination recommendations and revise thier policy to reflect updated guidance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R6) oxygen had physician orders for parameters to tirate (adjust) oxygen flow recieved by the resident in additon to the prescribed dose of delivery.

Inspectors wroteBased on on interview and document review the facility failed to have appropriate defined parameters to administer either 1 or 2 tablets of hydrocodone/acetaminophen 5-325 milligrams (mg) tablets for 1 of 1 resident (R134) with as needed (prn) medication administration orders for pain control based off assessment of R134's symptoms and pain management.

Inspectors wroteBased on observation and interview the facility failed to ensure hair nets were accessible upon entrance to the kitchen for staff and visitors and train staff where hairnets were accessible.

Inspectors wroteBased on interview and document review the facility failed to submit any data for staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (Quarter 2), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS.