The Gilbert Residence

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen.

Inspectors wroteBased on interview, and record review the facility failed to ensure accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for two residents (#7 and 33) of two residents reviewed for advance directives from a total sample of 9 residents. Resident #7 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident #7 (R7) was admitted to the facility on [DATE] with diagnosis that included vascular dementia and hypertension. The MDS revealed R7 had long and short-term memory impairment and severely impaired decision-making skills. A statement of decision-making capacity, signed by the Physician on 7/30/25 and signed by a psychologist on 7/22/25 revealed R7 was unable to fully participate in medical treatment decisions due to vascular dementia. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents were free from significant medication errors for one resident (#28) of four residents reviewed during medication administration. Findings Included:Resident #28 (R38)Review of the medical record revealed R28 was admitted to the facility 09/23/2025 with diagnoses that included atrial fibrillation, hyperlipidemia, sleep apnea, congestive heart failure (CHF), hypertension, muscle wasting, ischemic cardiomyopathy (damage of heart muscle), gastro-esophageal reflux disease, anxiety, and cerebral infarction (CVA). The most recent Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 09/23/2025, revealed R28 had Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. On 10/07/2025 at 08:56 a.m. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) effectively clean food service equipment (toaster), (2) ensure proper sanitizer concentration within the 3-compartment sink, and (3) effectively date mark all potentially hazardous ready-to-eat food products effecting 30 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, improper three-compartment sink sanitization, and resident foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform ongoing re-evaluation of the need for a restraint for one (Resident #25) of one reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their medication error rate was below 5% when four medication errors were observed from a total of 26 opportunities for three residents (Resident #2, Resident #3, and Resident #7) of six reviewed resulting in a medication error rate of 15.38%. Resident #3 (R3) Review of the medical record revealed R3 admitted to the facility on [DATE] with diagnoses that included dementia and seizures. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/24 revealed R3 was severely cognitively impaired. Review of the Physician's Order dated 5/7/18 revealed an order for topiramate 25 milligrams (mg) two tablets twice a day. The order did not specify that the medication could be crushed. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer an updated pneumococcal vaccine for one (Resident #2) of five reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 29 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician reviewed and acted upon identified medication regimen irregularities for four (Residents #'s 8, 13, 15 and 16) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate completion of advance directive information for one (Resident #24) of one resident reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) resulting in the potential for a resident's preferences for medical care to not be followed by the facility.

Inspectors wroteThis citation pertains to Intake number MI00134805. Based on interview and record review, the facility failed to immediately report to the State Agency an injury of unknown origin of one resident (Resident #30) of 1 reviewed for abuse, resulting in the potential of abuse to go unreported, undetected and the potential for further abuse to continue and go unrecognized.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment for one (Resident #29) of 12 reviewed for MDS assessments, from a total sample of 12, resulting in the potential for inaccurate care plans and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement person center care plans for 2 residents (#1 and #16) of 12 residents reviewed for care plans, resulting in the potential for unmet needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that pressure wounds were assessed, monitored and treated according to acceptable professional standards for one resident (#26) out of two reviewed with pressure ulcers resulting in the potential for worsening of pressure ulcers and delayed healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly transfer one Resident (#8) of 2 reviewed for falls, resulting in a fall, facial injuries, and need for emergency room transfer.

Inspectors wroteBased on interview and record review, the facility failed to complete an annual performance review and provide education based on the review for one staff member, Certified Nursing Assistant (CNA) F of 1 reviewed for yearly performance evaluation. This could potentially put all residents at risk for poor quality of care.

Inspectors wroteBased on interview and record review, the facility failed to integrate hospice and facility services and care plans to coordinate hospice care for one Resident (#29) of two resident reviewed for hospice services. This deficient practice resulted in the potential for care not being provided and lack of continuity of care between hospice staff and the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the results of the most recent federal surveys and corresponding plans of correction were readily accessible to all residents and representatives in the facility, with a census of 29 residents, resulting in the residents and representatives not being informed of identified deficiencies and solutions as written in the plan of correction.