Gilpin Hall

Inspectors wroteBased on record review and interview it was determined that for one (R4) out of four residents reviewed for accidents the facility failed to provide assistive devices to prevent an accident. R4 was transported in a facility vehicle without all safety straps secured. The facility driver came to a sudden stop and R4 fell forward and acquired two broken legs causing physical harm. The facility was found to be in past noncompliance with correction completed as of 1/8/26.

Inspectors wroteBased on observation, interview and record review, it was determined that for one (R1) out of five residents reviewed for resident rights, the facility failed to ensure that rights exercised by R1's resident representative were followed by staff.

Inspectors wroteBased on video observation, interview and review of facility documentation, it was determined that for one (R1) out of five residents reviewed for abuse, the facility failed to protect a resident's right to be free from physical and mental abuse by staff. While there was no apparent decline in mental or physical functioning of R1 at the time of the survey, it can be determined that a reasonable person in the same position would have experienced psychosocial harm, specifically dehumanization, as a result of the physical and mental abuse by staff. Review and verification of the facility's immediate actions for the staff to resident incidents on 8/2/25 and 8/20/25 were determined to have been corrected prior to the survey. An additional finding of a resident to staff incident, dated 8/31/25, was also captured on video, but was unknown to the facility until 10/3/25.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to have a surety bond that covered the current balance in the residents' trust accounts ($28,733.79).

Inspectors wroteBased on record review and interview, it was determined that for one (R81) out of one resident reviewed for misappropriation, the facility failed to protect R81's property. This is being cited as past non-compliance with a compliance date of 6/19/25.

Inspectors wroteBased on interview, record review and review of the facility's policy and procedures, it was determined that for two (R49 and R90) out of six residents reviewed for abuse, the facility failed to report the allegations of abuse and injury of unknown origin within the two-hour requirement.

Inspectors wroteBased on record review and interview, it was determined that for one (R96) out of one resident sampled for closed record review, the facility failed to notify the Ombudsman of R96's discharge to the community.

Inspectors wroteBased on record review and interview, it was determined that for two (R7 and R6) out of three residents reviewed for PASRR, the facility failed to coordinate with the PASRR program under Medicaid and refer the residents for assessments.

Inspectors wroteBased on record review and interview, it was determined that for one (R1) out of three residents reviewed for hospitalization, the facility failed to have evidence that the physician's order for a daily weight was completed.

Inspectors wroteBased on observation and interview, it was determined for two out of two medication rooms reviewed for storage of controlled substances, the facility failed to ensure that the locked boxes were permanently affixed to medication room refrigerators.8/27/25 10:12 AM - During a tour of the second-floor medication room, the storage box for the controlled substances was observed on top of the refrigerator. The third-floor controlled substances box was observed in refrigerator, but it was not permanently affixed. 8/28/25 9:30 AM - The second-floor medication room, the storage box for the controlled substances continued to be on top of the refrigerator. The third-floor controlled substances box continued to be in the refrigerator, but it not permanently affixed. [...]

Inspectors wroteBased on review of the facility's abuse policies and procedures and interview, it was determined that the facility failed to develop and implement an abuse policy that included all the requirements. The facility's policy lacked evidence of: established coordination with the QAPI program, required training regarding the signs of abuse and the different types of abuse, and failed to include language regarding the prohibition and prevention of retaliation for reporting.

Inspectors wroteBased on review of facility documentation and interview, it was determined that the facility failed to ensure that the monthly drug regimen review policy included time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.12/5/20 - A facility document entitled, Medication Regimen Review, revised 8/31/21, 2/23/23, 7/15/24, and 8/6/25, documented, Medications are reviewed in multiple ways including, but not limited to the MRR conducted by the consultant pharmacist 8/27/25 11:27 AM - A review of the facility's Medication Regimen Review lacked evidence of the time frames for the different steps in the process and steps the pharmacist must take when an irregularity is identified. [...]

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure: seven of 10 residents (Residents (R)69, R83, R89, R87, R20, and R67) reviewed for abuse were free from resident-to-resident abuse. These failures increased the risk of continued abuse towards the residents.

Inspectors wroteBased on observation, staff interviews, and review of the facility's policy, the facility failed to 1.) ensure staff changed gloves, performed hand hygiene, and followed proper cleaning techniques for one of one resident (Resident (R) 30) observed during incontinence care and one of one resident (R88) observed during wound care from a sample of 34 residents, and 2.) ensure staff followed recommended disinfectant drying times to disinfect a multi-use glucometer for two residents (R1 and R6) observed during medication pass. These failures increased the risk of cross contamination.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to notify the Resident Representative (RR) following a fall with injuries for one of three residents (Resident (R) 94) out of a total sample of 34 residents. The failure created a delay for R94 to have their RR to get to the hospital to see before R94's condition worsened.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide Form CMS-10055 (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to two of three residents (Resident (R) 10 and R77) reviewed for liability notices out of a total sample of 34 residents. This failure prevented the resident or responsible party the ability to make an informed decision related to the cost of continued therapy services.

Inspectors wroteBased on facility policy review, record review, and interviews, the facility failed to ensure their grievance procedures were followed for one resident (Resident (R) 79) of one resident reviewed for grievances out of a total sample of 34 residents. This failure increased the potential for resident grievances to go unresolved.

Inspectors wroteBased on review of facility policy, record review, and interview, the facility failed to ensure three of three residents (Residents (R) 20, R67, and R95) allegations of physical/verbal abuse were fully investigated out of sample of six residents reviewed for abuse out of a total sample of 34 residents. This lack of investigation had the potential to lead to continued episodes physical and verbal abuse.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 30) reviewed for accident hazards did not suffer a delay in treatment when the facility did not notify the physician of the delay in obtaining an x-ray as ordered. R30 experienced swelling to the right knee area and was administered non-narcotic pain medication for three days. The x-ray was obtained three days after being originally ordered and showed the resident had suffered an acute fracture to the distal femur.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one of four residents (Resident (R) 30) reviewed for accident hazards out of a total sample of 34 was transferred using the appropriate mechanical lift and number of staff as per the resident's plan of care.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to provide pain management that met professional standards for one of one resident (Resident (R) 30) reviewed for pain out of a total sample of 34 residents. R30 experienced swelling of the right knee area and received non-narcotic pain medication (Tylenol) while waiting three days for an x-ray. The facility failed to assess the resident's pain, failed to conduct pre and post pain medication assessments, and failed to indicate why Tylenol was administered to the resident. The x-ray revealed the resident had sustained a fracture to the right distal femur. Cross-Reference F684.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one Resident (R)83 was free from sexual abuse from R68. The facility also failed to ensure R47 was free from resident physical abuse from R143. Additionally, the facility failed to ensure R81 was free from sexual abuse from R73. Finally, the facility failed to ensure R51 was protected from verbal abuse by Certified Nursing Assistant (CNA) 5.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one resident (Resident (R) 32) out of the 36 sampled residents received their medication at the ordered time by the physician.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that one out of two residents (Resident (R) R24) observed during personal care were provided personal care in a manner that promoted infection control.