Gower Convalescent Center, Inc

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food safety when the facility staff thawed sausage in the refrigerator on a wire rack shelf above a box of sausage rolls and ground beef, when [NAME] B did not wash hands between glove changes while preparing and serving food, and additionally when [NAME] C sat two frozen chicken strips on a package of hamburger buns that still contained hamburger buns while waiting for the air fryer to heat up. This had the potential to affect all resident's. The facility census was 67. Review of the facilities Storage-Refrigerated Foods policy, not dated, showed: Place meat, poultry and seafood items on the lowest shelf to minimize leakage onto other stored foods. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their responsible parties, in advance of the risks and benefits of proposed care. When the facility failed to obtain written consent before beginning psychotropic medications (medications that affect the mind, emotions, and behavior) for three Residents (Resident #8, Resident #9, and Resident #19) of the 17 sampled residents. The facility census was 67. The facility did not provide a Psychotropic Medications policy. 1. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 04/24/26, showed:- Moderate cognitive impairment;- Independent with activities of daily living (ADL's);- Diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures to ensure resident trust accounts (RTF) were credited with interest monthly for three residents (Resident #33, #49, and #55) and failed to obtain written authorization for the disbursement of funds from the RTF for two residents (Resident #49 and #55). The facility census was 67. Request for facility policy on the Management of the RTF not provided.1. Review of Resident #33's Annual Minimum Data Set (MDS), a federally mandated assessment, dated 04/01/26, showed: - He/she had severe cognitive impairment;- Diagnoses: non-traumatic brain dysfunction, Alzheimer's disease and anxiety disorder. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain a system to ensure the resident trust fund (RTF) account was managed in accordance with proper accounting principles by not maintaining a monthly written reconciliation of all monies held in the resident trust fund account. The facility managed funds for 9 residents. The facility census was 67. Request for facility policy on the Management of the RTF not provided.1. Review of the monthly bank statements from April 2025 through March 2026 did not contain a written record of a reconciliation of the RTF account with the bank statements. During an interview on 05/21/26 at 9:25 A.M., the Business Office Manager (BOM) said:- She reconciles the RTF account monthly but does not record the reconciliation or have paperwork showing the account funds reconcile with the bank statements. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper respiratory care when staff failed to document the date when oxygen tubing was replaced for four residents (Resident #9, #11, #31, and #44), failed to ensure clean concentrator filters for one resident (Resident #11), and failed to provide proper storage for tubing (Residents #44) resulting in possible exposure to bacteria during oxygen usage and possible adverse effects. This affected four of 17 sampled residents. The facility census was 67. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure one of the 17 sampled residents, (Resident #10) received care which would allow the resident to achieve his/her highest practicable well-being. The facility census was 67. Review of the facility's Resident Rights Policy revised 8/25 showed:-As a resident, you have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the facility. -The facility must treat you with respect and dignity and care for you in a manner and in an environment that promotes maintenance or enhancement of your quality of life, while recognizing your individuality. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect Resident #1's right to be free from abuse when Resident #2 grabbed Resident #1 by the hair and jerked his/her head around. Facility census was 78. Review of the facility policy titled, Abuse and Neglect, dated 9/29/2017, showed: -The residents of the facility have the right to be free from physical abuse. Residents of the facility must not be subjected to abuse or neglect by anyone. It is the responsibility of our employees, facility consultants, attending physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to the facility management team. Our facility will not condone resident abuse by anyone. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to date the receipt of incoming products in the dry storeroom, label and date used products in the freezer and refrigerator, label, date and dispose of leftovers in the refrigerator, monitor refrigerator and freezer temperatures on a daily basis, and follow sanitation requirements for cleanliness, handwashing and hairnets in the kitchen and dining room. This affected all residents by putting them at risk for a food borne illness. The facility census was 78. Review of facility policy Hair Restraints for Dining Service, revised 10/26/21, showed: - Hair restraints shall be worn by all Dining Services staff when in food production, dishwashing areas or when serving food from the steam table. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assure staff treated residents in a manner that maintained their dignity, when staff did not serve all residents who sat at the same table during meals, which affected any resident who ate in the dining room, and failed to ensure one of the 18 sampled residents, (Resident #47), was free of facial hair. The facility census was 78. Review of the facility's policy titled, Resident Rights, revised 8/22, showed staff were directed to do the following: - The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the privacy of two of the 18 sampled residents, (Resident #43 and #73), when staff failed to post signage at the front door or outside each sampled resident's room to indicate 24 hour camera surveillance was in progress and failed to obtain consents from the responsible parties of the sampled residents. The facility census was 78. The facility did not provide a policy for video surveillance with or without audio. 1. Review of Resident #73's care plan, dated 9/20/24, did not address the use of video surveillance with audio. Review of the Resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, completed by facility staff, dated 11/20/24, showed: - Cognitive skills intact; - Dependent on the assistance of staff for toilet use, and transfers; [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure staff developed and updated care plans consistent with resident's specific conditions and needs which affected five of eighteen sampled residents (Resident #23, #47,#71, #6 and #12 ), and failed to invite and document quarterly care plan meetings were held for three residents (Resident #23, #6, and #12). The facility additionally failed to provide an accurate care plan when a resident had multiple transfer types listed in the care plan and did not reflect the resident's current non-ambulatory status for one resident (Resident #47) and failed to ensure wheelchair use was care planned for one resident (Resident #71). The facility census was 78. Facility did not provide a policy on comprehensive care plans. 1. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff provided professional standards of quality in care. when staff failed to utilize the electronic medical record to verify orders when providing wound care for one of the 18 sampled residents, (Resident #72) and when obtaining blood sugars and administering insulin for two residents (Resident #49 and #11) and additionally when staff failed to obtain physician's orders for wound treatment for Resident #5. The facility census was 78. Review of the facility's undated policy titled, Medication Administration, showed staff were directed to do the following: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff provided quality of care and treatment in accordance with professional standards of practice when staff failed to reposition two residents and provide incontinent care to dependent residents (Resident #47 and #72) This affected two residents out of eighteen sampled residents. The facility census was 78. Facility did not provide policy on positioning. 1. Review of Resident #47's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/26/24, showed: - Cognition severly impaired; - Dependent on a wheelchair for mobility and dependent of staff for turning, repositioning and transfers; - Total assist of all ADLS; - Diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure residents remained free from accident hazards when staff pushed residents in their wheelchairs without foot pedals for four (Resident #1, #68, #71, and #58) residents. This affected four of eighteen sampled residents. The facility census was 78. Facility did not provide a policy on accidents. 1. Review of Resident #1's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/19/24, showed: -Cognition severly impaired; -No impairment to upper or lower extremities; -Required assistance for Activities of Daily living to include transfers, mobility, hygiene needs. -Diagnoses included: Alzheimer's osteoarthritis , low back pain, unsteadiness on feet, and dementia Review of care plan, revised 9/12/24, showed: -He/She was ambulatory with assist; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to date when oxygen tubing was cleaned and left oxygen tubing lying on the ground for two residents (Resident #44, #21) resulting in possible exposure to bacteria during oxygen usage. Additionally the facility failed to keep water in the oxygen humidifier for proper humidity control for one resident (Resident #44) resulting in minor discomfort. This affected two of 18 sampled residents. The facility census was 78. Review of the facility's Oxygen administration policy not provided; 1. Review of Resident #44's Annual Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/2/24, showed: - Cognitive skills intact; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff maintained a medication error rate of less than five percent when nursing taff made two medication errors out of 25 opportunities for error, which resulted in a medication error rate of 8%, which affected two of the 18 sampled residents, (Resident #64 and #11). The facility census was 78. Review of the facility's undated policy titled, Medication Administration, showed staff were directed to do the following: - Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so; - Personnel authorized to administer medications do so only after sufficient information regarding the resident's condition and expected outcomes of medication therapy is known; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications for two residents (Residents #5, #44) were inaccessible to unauthorized staff and residents and failed to keep medications secured when the key was left in the lock of the medication treatment cart. Additionally the facility, failed to destroy expired and loose medications in the medication room and cart. This affected two out of 18 sampled residents. The facility census was 78. Review of facility Policy and Procedure for Physicians Orders, revised 1/15/12, showed - An interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment; - If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide required state approved training for paid feeding assistants which affected 18 residents. The facility census was 78. 1. A policy on paid feeding assistants was not provided for review. Review of a list of paid feeding assistants provided by the facility, dated 2/20/25, showed 5 feeding assistants with no state approved formal paid feeding assistant training. During an interview on 2/20/24 at 3:30 P.M., Nurse Aide (B) said: - He/she did not attend any formal state approved course for feeding assistant but instead got one on one training with the DON and experienced staff members; - He/she has been a feeding assistant for a few months and assists residents on the floor with meals; During an interview on 2/20/24 at 5:00 P.M., Director of Nursing (DON) said: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide proper infection control when facility staff did not immediately place one resident (Resident #23) on contact isolation precautions after readmitting to the facility with a positive test for influenza (a highly contagious respiratory illness of nose, throat, and lungs) A, did not have signage in place for (Resident #23) when on transmission based precautions, and did not cover clean laundry during transportation to prevent contamination. The facility census was 78. Review of facility policy, infection prevention and control policy and program, dated 3/12/21, showed: -Staff will reference the Centers for Medicare and Medicaid Services (CMS) guide and Center for Disease Control and Prevent (CDC) guidelines. These references will serve as the facilities guidelines to infection control. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards of food service safety when staff failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. This had the potential to impact all residents in the facility. The facility census was 68. Facility posted meal times included: Breakfast 7:00 A.M., hall trays at 9:00 A.M.; lunch at 12:00 P.M., hall trays start at 11:30 A.M., and supper at 5:00 P.M. with hall trays at 4:30 P.M. Review of facility policy- Three Sink Method of Sanitizing, dated 10/31/16, included: -In using a chemical sanitizer, the sanitizer must be mixed at the proper concentration of 200 parts per mission (PPM). During an observation on 10/23/23 at 11:15 A.M. showed sanitizer bucket tested at 0 parts per mission (PPM). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a base line care plan consistent with the resident's specific conditions, needs and risks to provide effective person centered care that met professional standards of quality care within 48 hours of admission to the facility and failed to ensure the resident and representative, if applicable, were informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan for two of the 17 sampled residents (Resident #45, and #18). The facility census was 68. The facility did not provide a policy on Baseline Care Plans. 1. Review of Resident #45's admission Minimum Data Set (MDS: A Federally mandated assessment tool completed by facility staff) showed: -Brief Interview of Mental Status (BIMS) of 99, indicated significant cognitive deficit. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for two of the 17 sampled residents (Residents #58, and #67). The census was 68. The facility did not provide a policy on Care Plans. 1. Review of Resident #58's significant change Minimum Data Set (MDS: A Federally mandated assessment tool completed by facility staff) dated 7/18/23., showed: -Brief Interview of Mental Status (BIMS) score of 99, indicated severe cognitive deficits. -He/she wanders 1-3 days. -Independent for Activities of Daily Living. -Always continent of bowel and bladder. -Diagnoses of : [...]

Inspectors wrote3. Review of Resident #16's quarterly MDS dated [DATE] showed: -Brief Interview of Mental Status (BIMS) of 9, indicated some cognitive deficit. -No shortness of breath and no use of O 2. -Limited to extensive assistance of staff with Activities of Daily Living (ADL's: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure they assessed residents for risk of entrapment from bed rails prior to installation and failed to ensure the bed's dimensions were appropriate for the resident's size and weight for four of the 18 sampled residents (Residents #17, #19, #27 and #40 ). The facility also failed to review the risk and benefits with the resident or the resident's representative and obtain informed consent prior to installation on one of eighteen sampled resident (Resident #19). The facility census was 68. The facility did not provide a policy on side rail assessments or entrapment assessments. 1. Review of Resident #17's quarterly minimum data set (MDS) a federally mandated assessment completed by facility staff, dated 9/6/23, showed: [...]

Inspectors wroteBased on record review and interview, the facility failed to failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia) when they failed to develop and implement a water management plan. The facility census was 68. Review of the facility's policy for Legionella Disease, dated October 1, 2023, showed: -This policy outlines measures to prevent and control Legionella disease; -Management: o the facility management is responsible for implementing and maintaining and effective Legionella disease preventions and control program; o Designate a Legionella control officer responsible for overseeing the program; -Prevention and Control Measures: o regularly assess and maintain the facility's water systems, including plumbing, and water heaters; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete regular inspection of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for four of the 18 sampled residents with side rails placing these resident's at risk for injury (Residents #17, #19, #27, and #40). The facility census was 68. The facility did not provide policy on side rail assessments or entrapment assessments. Review of the Food and Drug Administration's (FDA) document entitled Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated March 10, 2006 showed: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to revise comprehensive person centered care plans, when the facility failed to develop and revise an oral intake dietary care plan for Resident #67 who was previously dependent upon nourishment by a percutaneous endoscopic gastrostomy tube (PEG-tube, a tube inserted through the belly that brings liquid nourishment, hydration and medication directly to the stomach). The facility census was 68. The facility did not provide a policy on care plans. 1. Review of Resident #67's admission Minimum Data Set (MDS), A Federally mandated assessment completed by facility staff, dated 8/25/23, showed: -Brief interview mental status (BIMS) score, a mandatory tool used to screen and identify the cognitive condition of residents upon admission into long term care facility, showed level 9, indicating moderately impaired cognition; [...]