Gateway Care and Retirement

In the surveyor’s words

From the most serious findings on record at Gateway Care and Retirement, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 25, 2022

  Based on observation, interview, and record review it was determined the facility failed to ensure a supervised resident smoker did not have continued access to smoking materials for 1 of 8 sampled residents (#1). This failure to ensure Resident 1 was supervised while smoking and intoxicated resulted in Resident 1 sustaining second degree [CONDITION(S)] to her/his face, which was determined to be an immediate jeopardy situation in the area of CFR 483.25 Quality of Care. Findings include: Resident 1 was admitted to the facility 10/23/20 with diagnoses including [CONDITION(S)] (a neurological disorder that affects movement and muscle tone), [CONDITION(S)] and bilateral above the knee amputations. […]

• No harm, potential for more than minimal, widespreadF812Jul 15, 2025

  Based on observation, interview and record review it was determined the facility failed to properly store food and failed to maintain sanitary conditions in 1 of 1 kitchen. This placed residents at risk for foodborne illness and contaminated food. Findings include:The facility's Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices Policy dated 10/2017 indicated Employees must wash their hands: a. After personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); b. After using tobacco, eating or drinking; c. Whenever entering or re-entering the kitchen; d. Before coming in contact with any food surfaces; e. After handling soiled equipment or utensils; f. […]

• No harm, potential for more than minimal, widespreadF880Dec 4, 2023

  Based on observation, interview and record review it was determined the facility failed to adhere to transmission based precautions for 1 of 1 sampled residents (#107) reviewed for transmission based precautions and failed to process and transport laundry to prevent potential cross contamination for 1 of 1 laundry room reviewed for infection control. This placed residents at risk for infection. Findings include: 1. Resident 107 was admitted to the facility in 11/2023 with diagnosis including leg fracture. On 12/1/23 at 8:28 AM signage posted outside Resident 107's room indicated the resident was on transmission based precautions and staff were to don a mask, gloves, face shield and a gown when providing care. […]

• No harm, potential for more than minimal, widespreadF943Sep 13, 2022

  Based on interview and record review it was determined the facility failed to ensure staff received annual training on abuse, neglect, exploitation of resident property and dementia management for 9 of 10 randomly selected staff (#s 17, 18, 20, 21, 22, 23, 26, 27 and 28) reviewed for sufficient and competent nursing staff. This placed residents at risk for abuse, unmet needs and diminished quality of life. Findings include: The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last revised 4/2021, indicated the facility provided staff orientation and training programs that included topics such as abuse prevention, identification and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior. […]

• No harm, potential for more than minimal, widespreadF947Sep 13, 2022

  Based on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 4 of 5 randomly selected staff members (#s 19, 20, 22 and 23) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: The facility's In-Service Training Program, Nurse Aide, last revised 10/2017, indicated annual in-services must be no less than 12 hours per employment year. On 9/8/22 at 4:08 PM Staff 31 (Regional Nurse Consultant) provided a spreadsheet of trainings and confirmed the following: -Staff 19 (CNA): 8 hours of training, -Staff 20 (CNA): 10 hours of training, -Staff 22 (CNA): 4 hours of training and -Staff 23 (CNA) 3 hours of training. […]