Gillespie Health & Rehab Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to implement an individualized transfer plan, initiate and implement appropriate interventions for 4 of 8 residents (R20, R9, R17 and R39) reviewed for accidents in the sample of 39.The findings include: 1 On 5/20/2026 at 9:02AM V24 Certified Nursing Assistant (CNA) and V23 CNA transferred R20 from wheelchair to bed with mechanical lift. Prior to transfer R20 sitting in wheelchair with sling in place. After attaching sling straps to the lift. V23 CNA operated the lift. V24 held on to sling and V24 placed her right foot on bar underneath wheelchair that attaches to wheel of wheelchair. R20's Minimum Data Sheet (MDS) dated [DATE] documents R20 is cognitively intact with a Brief Interview of Mental status (BIMS) of 15. R20's MDS documents R20 is dependent on staff for chair to bed transfer. R20's care plan dated 10/20/2025 document R20 needs assistance with Activities of Daily Living (ADL's) related to limited Range of Motion (ROM) to bilateral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview the facility failed to initiate a physician ordered antibiotic timely for 1 of 1 resident (R2) reviewed for Urinary Tract Infection (UTI) in the sample of 4.Findings include:1. On 9/17/2025 at 8:59AM R2 stated she had symptoms of Urinary Tract Infection (UTI) and a specimen to the lab and results had been sent to the physician, but (the physician) was in the hospital. R2 stated she was not receiving an antibiotic for a UTI. R2 stated she has had UTI's in the past and septic. R2's culture report dated 9/15/2025 documents greater than 100,000 Eschericia Coli in urine. R2's report (faxed back to the facility from the physician) documents Macrobid (antibiotic) 100 milligrams (mg) twice a day (BID) x10 days dated 9/16/2025. R2's Medication Administration Records dated 9/16/25 did not document the initiation/administration of physician ordered Macrobid. R2's current face sheet dated 9/17/2025 documents R2 has a diagnosis in part of chronic kidney disease, stage 4 (severe), and personal history of urinary tract infection. On 9/17/2025 at 12:44PM V1,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to provide complete incontinent and peri care to 3 of 3 residents (R1, R2, and R3) reviewed for incontinent care in the sample of 4. Findings include: 1.On 9/17/2025 R2 placed on bedpan per V6 and V7, Certified Nursing Assistants (CNA'S). R2 voided on the bedpan. Both V6 and V7 removed bedpan from under R2. V6, CNA cleansed R2's bilateral groin, inner thighs, wiped peri area front to back. V6 did not separate R2's labia. V6 rinsed and dried all areas, prior to V6 and V7 turning R2 on side to cleanse buttocks and rectal area. R2's current face sheet dated 9/17/2025 documents R2 has a diagnosis in part of chronic kidney disease, stage 4 (severe), and personal history of urinary tract infection. R2's urine Culture results dated 9/15/2025 documents equal or greater 100,000 Escherichia Coli. R2's Care plan dated 5/11/2023 documents R2 is at risk for impaired skin/ deep tissue injury related to immobility, obesity, incontinence of bowel and bladder.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a multi dose vial with a shelf life of 30 days was dated to indicate when it was opened and failed to ensure a bottle of controlled substance medication was labeled the residents name and physician's order. This failure has the potential to affect all 63 residents residing in the Facility. Findings include: 1. On 4/14/2025 at 2:52 PM the medication storage room and mediation cart were inspected with V10, Licensed Practical Nurse (LPN). 1. There was a bottle of Morphine Sulfate (Opioid pain medication/controlled substance) in a locked box. Neither the bottle or the box was labeled with a name or physician's orders. At this, time V10 stated the medication had been opened and there had been medication used from the bottle. V10 stated, I don't know whose (medication bottle) that is. That one doesn't even have a name on the box. During this observation, V2, Director of Nursing (DON) entered the medication storage room. V2 stated, That one (morphine bottle) is (R17's). It needs wasted. She doesn't have an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to provide substitute food choices for 5 of 24 residents (R16, R28, R30, R49, R63) reviewed for meals. Findings include: 1. On 04/14/25 at 12:25 PM, R63 was served her lunch by V6, Dietary Manager, R63 was served a grilled cheese sandwich. R63 stated she wanted turkey. V6 stated she would get her turkey. V6 returned with the turkey. The turkey was on bread and had gravy on top. R63 stated I just want turkey that I could cut up with my knife and eat with a fork. V6 stated, How about a sandwich. V6 folded the turkey into a sandwich and walked away. On 4/15/25 at 2:35 PM, V1, Administrator, stated R63 should have been given plain turkey. V1 stated, She doesn't eat that much already. R63's Face Sheet, print date of 4/15/25, documents R63 was admitted on [DATE] and has diagnoses of Dementia and severe Protein Calorie Malnutrition. R63's Minimum Data Set, (MDS), dated [DATE], documents R63 is severely cognitively impaired and requires set up clean…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 4. R55's admission Record, dated 4/16/25, documents R55 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction with Hemiplegia and Hemiparesis, Dysphagia, Emphysema, Asthma, Congestive Heart Failure, Major Depressive Disorder, Generalized Anxiety Disorder, Malignant of Neoplasm of Sigmoid Colon, Gastrointestinal Hemorrhage, and Diverticulitis. On 4/15/25 at 1:05 PM, R55 used call light to let staff know he had to use restroom. V4, CNA, assisted R55 to the toilet to have bowel movement (BM). When finished, V4 wiped R55's buttocks and anal area with a wet washcloth sprayed with peri-wash, then dried R55. Using the same soiled gloves, V4 then pulled R55's incontinence brief and pants up, adjusted R55's shirt, and assisted R55 back to his wheelchair, then removed her soiled gloves. 5. R216's admission Record, dated 4/16/25, documents R216 was admitted to the facility on [DATE] with diagnoses of Cerebral Vascular Accident (CVA), Aphasia, Dysphagia, Chronic Kidney Disease-stage 2, Hypertension,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely and complete incontinent care for three of seven residents (R31, R38, R216) reviewed for incontinence care in the sample of 49. The Findings Include: 1. R38's admission Record, dated 4/16/25, documents R38 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease-stage 3, Hypertension, Descending Thoracic Aorta Aneurysm, Cerebral Infarction without residual deficits. R38's Care Plan, dated 3/20/25, documents R38 has a Self-Care Deficit as Evidenced by: Needs assistance with ADLs (activities of daily living). Interventions: Toilet Use - One-person physical assist required. It continues R38 has a Potential for impaired skin integrity related to: falls, impaired mobility, occasional incontinence. Interventions: Provide peri-care as needed. R38's Minimum Data Set (MDS), dated [DATE], documents R38 has a severe cognitive impairment and requires setup or clean-up assistance for toileting, partial/moderate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to check placement of a J-tube (Jejunostomy) and label enteral feeding for 1 of 1 resident (R50) reviewed for tube feeding in the sample of 49. Findings include: On 4/15/25 at 12:30 PM, V14, Licensed Practical Nurse, entered R50's room. R50 has a J-tube for medications and feedings. V14 stopped R50's tube feeding, disconnected the tube feeding, administered 30 milliliters (ml) of water, the hydroxyzine cocktail, and flushed with another 30 ml of water. V14 stated, I have to go and get another ruler. I dropped the one I had. V14 left the room and returned with another ruler and measured the length of the J-tube. On 4/15/25 at 12:40 PM, R50's hanging disposable tube feeding bag is dated 4/15/25. The bag fails to document what type of feeding or rate of the feeding. On 4/15/25 at 12:40 PM, V14 stated, I should have measured the J-tube before I administered the medications. I recently hung a new disposable tube feeding bag and filled it with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to justify the use of an antibiotic and utilize infection surveillance when considering initiation of an antibiotic for 2 of 4 (R32, R41) residents reviewed for antibiotic stewardship in the sample of 49. Findings include: 1 On [DATE] at 10:57 AM, V3, Infection Preventionist was questioned on how she tracks the infections in the facility. V3 stated she looks at the 24-hour report for new antibiotic orders, checks the order, and puts that information on the tracking sheet that she uses. V3 stated that the computer program infection tracker has the information on McGreer and the cultures if any were obtained. V3 was asked to pull up R41's McGreer assessment for a urinary tract infection that is on the monthly infection tracking log. V3 pulled up the McGreer and stated, I am not sure how the system works because it never tells you if they qualify for a true infection. V3 was questioned what symptoms R41 presented with to get a urine culture, V3 stated, Her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure resident's advance directives and physician's orders reflected resident's wishes for 2 of 3 residents (R41 and R58) reviewed for advance directives in a sample of 25. Findings include: 1. R41's Face Sheet, with original admission date of [DATE], documents R41 has diagnoses of but not limited to chronic combined systolic (congestive) and diastolic (congestive) heart failure, chronic obstructive pulmonary disease with (acute) lower respiratory infection, atherosclerotic heart disease, and chronic atrial fibrillation. R41's Minimum Data Set (MDS), dated [DATE], documents R41 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 06 out of 15 and she is dependent on staff for most of her activities of daily living (ADLs). R41's Care Plan, not dated, documents Resident desires CPR be initiated in the event of cardiac arrest, resident wishes will be honored thru next review, Full Code/CPR, In the event of cardiac arrest,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure medications are labeled and stored appropriately until they are administered for 4 of 4 residents (R4, R21, R23, R32) reviewed for medication storage in the sample of 34. Findings include: On 5/24/23 at 7:50 AM, V7, Licensed Practical Nurse (LPN), was observed doing the AM medication pass on the 100 and 200 Halls. When V7 opened the top drawer of the medication cart, there were three medication cups containing multiple pills and capsules. These cups were labeled with R4's, R21's, and R23's names, but no other identifying information or dates were written on the cups. There were two cups of clear fluid on top of the medication cart. 1. R4's Physician Order Summary dated 5/24/23 documents he takes the following medications in the morning: Fluoxetine 10 milligram (mg), Ergocalciferol 2000 units (u), Carbidopa-Levodopa 25-100 mg 2 tabs, Vitamin B12 1000 micrograms (mcg), Miralax 17 Grams (Gm), Aspirin 81 mg, Acetaminophen 325 mg 2 tablets, Odansatron 4 mg, and Trihexyphenidyl 1 mg. On 5/24/23 at 8:25 AM, V7…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to follow up on Registered Dietitian's (RD) recommendations for residents with significant weight loss and ensure RD recommendations are implemented in a timely fashion in 2 of 5 residents (R14, R48) reviewed for nutrition in the sample of 34. Findings include: 1. R14's Face Sheet documents R14 has diagnoses including chronic atrial fibrillation, obstructive sleep apnea, vitamin D deficiency, Barrett's Esophagus without dysplasia, essential (primary) hypertension, and age-related cognitive decline. R14's Minimum Data Set (MDS) dated [DATE] documents R14 was severely cognitively impaired, walked independently, and had no significant weight loss. R14's Care Plan dated 4/18/23 documents, I may be at risk for nutritional problems r/t (related to) age related cognitive decline. The Facility's Weight Losses list documents R14 as a resident who has lost weight. R14's Weight and Vitals Summary dated 5/25/23 documents R14 weighed 155.9 pounds on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.