A list of the most recent deficiencies for Gilpin Hall. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-14 | 2024-01-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-14 | 2024-01-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-14 | 2024-01-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-28 | 2022-09-16 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-03 | 2021-10-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-08-03 | 2021-10-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-03 | 2021-10-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-08-03 | 2021-10-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-03 | 2021-10-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-03 | 2021-10-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-08-03 | 2021-10-01 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-08-03 | 2021-10-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-03 | 2021-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-03 | 2021-10-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-08-03 | 2021-10-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-03 | 2021-10-01 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-08-03 | 2021-10-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-03 | 2021-10-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-03 | 2021-10-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-03 | 2021-10-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-03 | 2021-10-01 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-05-16 | 2019-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-16 | 2019-08-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-05-16 | 2019-08-12 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-05-16 | 2019-08-12 | N |
| Provide or obtain dental services for each resident. | Health | 2019-05-16 | 2019-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-16 | 2019-08-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-05-16 | 2019-08-12 | N |
| Use approved construction type or materials. | Fire Safety | 2019-05-14 | 2019-06-10 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-05-10 | 2018-06-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-10 | 2018-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-10 | 2018-06-14 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-05-10 | 2018-06-14 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-05-10 | 2018-06-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-10 | 2018-06-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-10 | 2018-06-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-05-10 | 2018-06-14 | 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 | 2018-05-10 | 2018-06-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-05-10 | 2018-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-10 | 2018-06-14 | N |
| Dispose of garbage and refuse properly. | Health | 2018-05-10 | 2018-06-14 | N |
| Use approved construction type or materials. | Fire Safety | 2018-05-11 | 2018-06-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-11 | 2018-06-06 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2018-05-11 | 2018-06-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-05-11 | 2018-06-06 | N |
