Gil-Mor Manor

In the surveyor’s words

From the most serious findings on record at Gil-Mor Manor, in the surveyor’s own words.

• Immediate jeopardy, widespreadF888May 27, 2022

  Based on observation, interview, and document review, the facility failed to develop and implement COVID vaccination policies and procedures to ensure appropriate staff COVID-19 vaccination or exemptions for 3 of 72 staff who were not vaccinated nor had they any approved religious or medical exemption. The facility also failed to develop and implement policy and procedures for mitigating potential transmission of COVID for 15 of 72 staff with approved religious exemptions. The facilities failures resulted in 7 of 27 of residents (R2, R3, R4, R5, R9, R21, and R25) contracting COVID-19. The IJ began on 5/7/22 when 1 of 7 residents (R2) became positive for COVID-19 after repeated staff COVID-19 outbreak infections since December 2021. […]

• No harm, potential for more than minimal, widespreadF812Sep 10, 2026

  Based on observation, interview and document review the facility failed to ensure test strips used to test chemical concentration in a low temperature dishwasher were not outdated, and the tests were performed according to the manufacture's guidelines. This had the potential to affect all 33 residents who received meals at the facility.Findings include: Observation and interview on 9/8/26 at 12:59 p.m., of the facility kitchen, with the certified dietary manager, (CDM) identified the facility utilized a low temperature, chemical dishwasher. The CDM reported the representative came monthly and as needed to check the chemical concentration. […]

• No harm, potential for more than minimal, widespreadF755Jul 24, 2025

  Based on observation, interview, and document review the facility failed to ensure emergency medications stored in 1 of 1 medication storage room were not expired.Findings include: Observation and interview on 7/23/25 at 12:33 p.m., with licensed practical nurse (LPN)-A of the medication room identified the emergency medication kit (E-kit) was observed sitting on the counter. On the top of the E-kit a sticker was observed that said exp (expiration) 6/27. LPN-A was not certain if that meant the medications in the E-kit expired on 6/27/25 or June of 2027. Observation of the medications inside the E-kit identified 2 Morphine filled syringes 4 milligrams/milliliter (mg/mL). The manufacturers expiration date printed on the syringe was June of 2025. […]

• No harm, potential for more than minimal, widespreadF880Jul 24, 2025

  Based on interview and document review, the facility failed to have a thorough, ongoing infection control surveillance program that included resolution of symptoms and/or if any transmission-based precautions (TBP) had been implemented during 3 of 3 months reviewed (April, May, and June of 2025). The facility also failed to identify when employees would be able to return to work after having signs and symptoms of potential Norovirus for 8 of 8 staff (Cook-A, nursing aide (NA)-A, Cook-B, dietary (aide)-A, trained medication aide (TMA)-A, the infection preventionist (IP), NA-B, and TMA-B) reviewed for January of 2025.Findings include: Resident SurveillanceReview of resident surveillance for April, May, and June of 2025, identified a form included the wing of the facility, resident name, and… […]

• No harm, potential for more than minimal, widespreadF882Jul 24, 2025

  Based on interview and document review, the facility failed to ensure 1 of 1 infection control preventionist (IP) had provided oversight of the infection control program and the antibiotic stewardship program.Findings include: Review of monthly resident surveillance for April 2025 through June 2025, identified columns to document location within the facility, resident name, onset date, type of illness, signs and symptoms, mental status changes, organism, treatment and dates, resolution, and comments. The form lacked a column for antibiotic time-out and/or if precautions were implemented. The form was not completed in full as the resolved date had not been identified and documented. […]