Gateway Transitional Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jul 11, 2024

  Based on observation, record review, and staff interview, it was determined the facility failed to ensure the kitchen was maintained in a sanitary manner when sanitizer solutions were had inadequate strength, rust was observed on the inside of the ice machine, and the dishwashing area contained caulking that was peeling off with food particles entrapped creating a surface that was uncleanable on the stainless counter. These deficiencies had the potential to affect all 76 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: 1. The initial kitchen inspection was conducted on7/8/24 from 9:45 AM through 10:28 AM with the DS. […]

• No harm, potential for more than minimal, patternF689Jul 24, 2025

  Based on observation, record review, and interviews, it was determined the facility failed to assess the risks of transporting residents backwards in Geri-Chairs and had not provided attentive care during resident transports in Geri-Chairs. This was true for 1 of 2 residents (Resident #12) who was observed during transport down the facility's C-Hallway. This deficient practice placed residents at risk for harm when improperly transported and supervision was not provided. Findings include:Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including cerebellar ataxia (a group of neurological disorders that affect the cerebellum, the part of the brain responsible for coordination and balance), cognitive communication deficit, and muscle spasms.On 7/22/25 at 3:37 PM,… […]

• No harm, potential for more than minimal, patternF695Jul 24, 2025

  Based on policy review, observation, record review, and interviews, it was determined the facility failed to a) provide respiratory services as ordered by the physician and b) ensure physician orders and resident care plans identified interventions for oxygen therapy. This was true for 5 of 13 residents (#3, #5, #9, #28, and #59) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels. […]

• No harm, potential for more than minimal, patternF732Jul 11, 2024

  Based on observation, policy review, record review, and staff interview, the facility failed to ensure the required nursing staff posting accurately reflected the actual staff hours to care for the 76 current residents and failed to ensure the posting included an updated census for each shift. This failure had the potential to inaccurately inform any resident, family member, or visitor to the facility of the available nursing staff caring for residents. Findings include: On 7/9/24 at 3:05 PM, a posted nurse staffing was not observed in the R and D/C hall Nurse's Stations. […]

• No harm, potential for more than minimal, isolatedF554Jul 24, 2025

  Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were assessed to determine if they were safe to self-administer medications for 1 of 6 residents (Resident #83) reviewed for self-administration of medications. This failure created the potential for adverse effects if residents self-administered medications inappropriately. Findings include: Resident #83 was admitted to the facility on [DATE], with multiple diagnoses including atrial fibrillation (irregular heartbeat that may cause the heart to beat faster) and diabetes.On 7/23/25 at 11:54 AM, observed a bottle of artificial tears on Resident #83's bedside table.Review of Resident #83's medical record contained a Self-Administration of Medications - Initial Evaluation dated… […]