Gates Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Gates Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF607Mar 17, 2022

  Based on record reviews and staff interviews the facility failed to implement their abuse policy and procedure by not reporting Resident to Resident altercation to the facility Administrator immediately for 2 of 2 Residents reviewed (Resident #151 & #41) for abuse. The findings included: The facility's policy titled Abuse, Neglect, and Exploitation updated on 10/22/20 stated reporting of all alleged events will be made to the facility Administrator immediately. Resident #41 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #151 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . His Minimum Data (MDS) dated [DATE] indicated he was severely cognitively impaired. […]

• Actual harm, isolatedF689Mar 17, 2022

  Based on record review, staff, Resident and Physician interviews the facility failed to provide supervision to prevent a severely cognitively impaired Resident (Resident #151) from wandering into another Resident's room (Resident #41) resulting in an altercation and Resident #151 sustaining a right humeral (upper arm bone) fracture. This was for 1 of 2 Residents reviewed for supervision to prevent accidents. The findings included: Resident #151 was admitted to the facility on [DATE] with diagnoses that included history of seizures, stroke like episode, and [CONDITION(S)]. The Minimum Data Set (MDS) dated [DATE] indicated Resident #151 was severely cognitively impaired. There were no behaviors, verbal or physical, noted toward others in the 7 day assessment period of the MDS. […]

• No harm, potential for more than minimal, widespreadF812Aug 15, 2025

  Based on observation and staff interviews, the facility failed to keep 1 of 1 walk-in refrigerator walls free of a dark black/green substance. The Findings Included: An initial tour of the kitchen was conducted on 8/12/2025 at 10:20 am. A dark black /green substance was observed on all four walls of the walk-in refrigerator. An area located under the refrigerator rack and adjacent to the walk-in freezer door was observed to have a large area of a dark black/green substance in the corner that extended to the floor. An interview and observation were conducted on 8/12/2025 at 10:25 am of the walk-in- refrigerator with the Dietary Manager. Upon observation of the walk-in refrigerator, the Dietary Manager stated she did not know what the substance was on the walk-in refrigerator walls. […]

• No harm, potential for more than minimal, patternF585Aug 14, 2024

  Based on record review and interviews with resident and staff, the facility failed to ensure the resident's right to file a grievance and receive written notification of the decision regarding the grievance investigation for 4 of 5 residents reviewed for the grievance process. (Resident #17, Resident #9, Resident #22, and Resident #21) The findings included: Review of the facility policy dated 3/8/22 titled Grievance Policy read in part: 7. The facility must ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident ' s grievance, the steps taken to investigate the grievance, a summary of the pertinent finding or conclusions regarding the residents ' concerns, a statement as to whether the grievance was confirmed or not… […]

• No harm, potential for more than minimal, patternF925Aug 14, 2024

  Based on observations, record review, resident and staff interview the facility failed to maintain an effective pest control program as evidenced by the presence of flies on 2 of 5 Hallways that affected resident rooms 117, 118, 121, 122, and 123. The findings included: Review of the pest control receipt for 6/28/24 read: inspected and treated select areas with a focus on kitchen. Performed exterior rodent services, checked accessible bait stations and replaced bait as needed. No rodent or insect activity was noted during inspection and/or service. There was no mention of a fly program service. Review of the pest control receipt for 7/31/24 read: inspected and treated select areas. Performed exterior rodent services, checked accessible bait stations and replaced bait as needed. […]