Gillespie Health & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Gillespie Health & Rehab CTR, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 7, 2022

  Based on observation, interview, and record review, the facility failed to provide safe transfers for 1 of 6 residents (R31) reviewed for accidents in the sample of 32. This failure resulted in R31 sustaining a laceration to the Right posterior calf requiring being sent to the emergency room and receiving 7 sutures. Findings include: 1. On 04/05/22 at 1:00 PM , V2, Regional Nurse, stated that V2 had received a call from previous Director Of Nursing (DON) reporting that when staff were transferring R31 to bed with partial mechanical lift and R31's legs became weak while still in the partial mechanical lift and moved over bed causing laceration to R31's right calf. […]

• Actual harm, isolatedF692Mar 17, 2021

  Based on interview, observation and record review, the facility failed to report weight loss to the Physician and develop and implement interventions to prevent further weight loss for 2 of 9 residents (R34, R39) reviewed for weight loss in the sample of 33. This resulted in R34's severe weight loss of 8% in one month. Findings include: 1. R34's Admission Record, print date of 3/9/21, documents R34 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's Minimum Data Set (MDS), dated [DATE], documents R34 is moderately impaired for cognitive thinking and requires extensive assist of 1 staff member for feeding. R34's weight log, dated documents on 1/10/21, R34 weighed 136.5 pounds and on 2/10/21, R34 weighed 124.5 pounds. This was a severe weight loss of >8% in one month. […]

• Actual harm, isolatedF697Mar 17, 2021

  Based on observation, interview and record review the facility failed to reassess pain regimen for 1 of 3 residents (R54) reviewed for pain in a sample of 33. This failure resulted in R54 continuing to experience pain with care and a physical decline in her function abilities. Findings include: R54's Care Plan, dated 2/26/2021, documents in part, I am on scheduled Pain medication Therapy r/t (related to) arthritis. Interventions Administer medication as ordered. Review for pain medication efficacy. […]

• No harm, potential for more than minimal, widespreadF725May 21, 2026

  Based on observation, record review, and interview, facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. This has the potential to affect all 75 residents residing in the facility.Findings include:1.R85's Facesheet with a print date of 5/21/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, sepsis, chronic obstructive pulmonary disease and type two diabetes mellitus. R85's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact, required substantial/maximal assistance with toileting hygiene and partial/moderate assistance with toilet transfers from staff. […]

• No harm, potential for more than minimal, widespreadF761May 21, 2026

  Based on observation, interview, and record review, the facility failed to properly store, label, and discard expired medication. This has the potential to affect all 75 residents residing in the facility.Findings include:On 5/18/2026 at 10:34 AM the 300/400 Medication Cart was inspected. The medication contained:1. R68's open and partially used multidose Novolog Pen. No open date on pen.2. R59's open and partially used multidose Novolog Pen. No open date on pen.3. R89's open and partially used multidose Artificial eye drops bottle. No open date in place.4. R6's open and partially used multidose Timolol eye drops bottle. No open date in place.5. 1 open and partially used bottle of Ofloxacin Ophthalmic solution. […]