A list of the most recent deficiencies for Gateway Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-10 | 2024-01-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-12 | 2023-12-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-16 | 2023-08-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-26 | 2023-05-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-26 | 2023-05-05 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-11-04 | 2022-12-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-04 | 2022-12-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-04 | 2022-12-09 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-11-04 | 2022-12-09 | N |
| Provide activities to meet all resident's needs. | Health | 2022-11-04 | 2022-12-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-11-04 | 2022-12-09 | N |
| Provide appropriate foot care. | Health | 2022-11-04 | 2022-12-09 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-11-04 | 2022-12-09 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-11-04 | 2022-12-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-11-04 | 2022-12-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-04 | 2022-12-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-11-04 | 2022-12-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-08 | 2022-12-08 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-11-08 | 2022-12-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-20 | 2022-10-04 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-03-04 | 2022-03-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-24 | 2022-03-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-28 | 2021-07-12 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-07-31 | 2019-08-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-07-31 | 2019-08-23 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-07-31 | 2019-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-31 | 2019-08-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-31 | 2019-08-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-07-31 | 2019-08-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-07-31 | 2019-08-23 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-27 | 2019-07-23 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-27 | 2019-07-23 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-06-27 | 2019-07-23 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-06-27 | 2019-07-23 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-06-27 | 2019-07-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-06-27 | 2019-07-23 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-27 | 2019-07-23 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-06-27 | 2019-07-23 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-06-27 | 2019-07-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-06-27 | 2019-07-23 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-27 | 2019-07-23 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-06-27 | 2019-07-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-09-28 | 2018-10-17 | N |
| Use approved construction type or materials. | Fire Safety | 2018-09-28 | 2018-10-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-28 | 2018-10-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-28 | 2018-10-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-09-28 | 2018-10-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-09-28 | 2018-10-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-28 | 2018-10-17 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-07-12 | 2018-08-09 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-07-12 | 2018-08-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-12 | 2018-08-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-07-12 | 2018-08-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-12 | 2018-08-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-07-12 | 2018-08-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-07-12 | 2018-08-09 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-07-12 | 2018-08-09 | N |
| Provide activities to meet all resident's needs. | Health | 2018-07-12 | 2018-08-09 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-07-12 | 2018-08-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-07-12 | 2018-08-09 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-07-12 | 2018-08-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-07-12 | 2018-08-09 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2018-07-12 | 2018-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-12 | 2018-08-09 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-07-12 | 2018-08-09 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-07-12 | 2018-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-12 | 2018-08-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-07-12 | 2018-08-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-07-12 | Not Fixed | N |
