A list of the most recent deficiencies for The Gilbert Residence. 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? |
|---|---|---|---|---|
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-09-25 | 2023-11-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-25 | 2023-11-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-25 | 2023-11-15 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-09-25 | 2023-11-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-25 | 2023-11-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-25 | 2023-11-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-25 | 2023-11-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-09-28 | 2023-11-02 | N |
| 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 | 2023-09-28 | 2023-11-02 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-09-28 | 2023-11-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-28 | 2023-11-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-28 | 2023-11-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-11-02 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-28 | 2023-11-02 | 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 | 2023-09-28 | 2023-11-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-28 | 2023-11-02 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-09-28 | 2023-11-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-28 | 2023-11-02 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-08-11 | 2022-08-24 | 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 | 2022-08-11 | 2022-08-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-11 | 2022-08-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-11 | 2022-08-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-11 | 2022-08-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-11 | 2022-08-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-11 | 2022-08-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-11 | 2022-08-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-12 | 2021-07-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-12 | 2021-07-07 | 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 | 2021-05-12 | 2021-07-07 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-05-12 | 2021-07-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-12 | 2021-07-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-12 | 2021-07-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-05-12 | 2021-07-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-12 | 2021-07-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-05-12 | 2021-07-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-12 | 2021-07-07 | N |
| 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 | 2021-05-12 | 2021-06-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-05-12 | 2021-06-16 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-05-12 | 2021-06-16 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-05-12 | 2021-06-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-12 | 2021-06-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-12 | 2021-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-12 | 2021-06-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-05-12 | 2021-06-16 | 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 | 2021-05-12 | 2021-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-12 | 2021-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-12 | 2021-06-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-12 | 2021-06-16 | N |
