Gillette Nursing Home

In the surveyor’s words

From the most serious findings on record at Gillette Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF584Apr 7, 2025

  Based on observation, interview, record review and review of facility policy, the facility did not ensure all shower rooms used by residents were maintained at comfortable temperatures. This affected four residents (Residents #4, #9, #23 and #26) and had the potential to affect all residents in the facility excluding 37 residents ( #1, #2, #3,#8, #10, #12, #13, #15, #16, #17, #21, #24, #25, #27, #34, #35, #38, #42, #43, #46, #50, #51, #54, #56, #58, #59, #61, #62, #64, #66, #70, #72, #73, #77, #78, #80, and #84) the facility identified as having personal showers in their resident rooms. The facility census was 87. Findings include: 1. A facility tour was conducted on 03/24/25 at 10:30 A.M. with Maintanence Director (MD) #257 and revealed the facility had two shower rooms for resident use. […]

• No harm, potential for more than minimal, patternF584Aug 8, 2024

  Based on observation, staff and resident interviews, and review of the Resident Council meeting minutes and facility policy, the facility failed to ensure residents rooms on the 600 hall were homelike as evidenced by the walls being in disrepair. This affected 20 residents (#1, #2, #3, #14, #16, #26, #29, #30, #32, #39, #41, #45, #47, #70 #76, #77, #88, #52, #91, #197) out of the 43 residents who resided on the 600 hall. The facility census was 94. Findings include: Interview on 08/05/24 at 2:41 P.M. with Resident #26 revealed when asked about the black scrape marks and gouges in the wall behind her recliner, the resident stated she hadn't done that to the wall, and it bothered her since she kept thinking there were bugs on the wall. […]

• No harm, potential for more than minimal, patternF803Aug 8, 2024

  Based on observation, interviews, and review of the facility Spring and Summer 2024 menu, the facility failed to ensure nutritionally equivalent food substitutions were made and provided for Resident #46, #66, #81, #83 and #145. This affected five residents (#46, #66, #81, #83, and #145) out of the 91 residents who the facility identified as receiving meals from the kitchen. The facility identified three residents (#9, #41, and #55) as receiving no meals from the kitchen. The facility census was 94. Findings include: Review of the facility Spring/Summer 2024 menu cycle for day 10 revealed for lunch a chili dog, baked beans, country potatoes, and watermelon was to be served. Observation of tray line on 08/06/24 between 11:38 A.M. to 12:22 P.M. revealed at 12:21 P.M. […]

• No harm, potential for more than minimal, isolatedF689Jul 31, 2025

  Based on record review, interview and review of facility policy, the facility failed to conduct complete and thorough post-fall investigations to mitigate risk of falls . This affected one resident (Resident #94) of four residents reviewed for falls. The facility census was 93.Findings include: Record review for Resident #94 revealed an admission date of 05/23/25 with diagnoses including unspecified dementia, anxiety, difficulty walking, malnutrition and right femur fracture. Pertinent physician orders included non-skid pad to wheelchair, body pillow to open side of bed, non-skid pad to wheelchair cushion, floor mat to open side of bed, non-skid socks on at all times, brake sentry to wheelchair, and physical therapy evaluate and treat.Review of the Minimum Data Set (MDS) 3.0 assessment… […]

• No harm, potential for more than minimal, isolatedF609Apr 7, 2025

  Based on record review, staff interview, and facility policy review, the facility failed to timely report an allegation of misappropriation of narcotic medications to the appropriate state agency. This affected two residents (#33 and #65) of three residents reviewed for misappropriation. The facility identified an additional 21 residents (#7, #14, #17, #18, #24, #26, #28, #31, #32, #59,#60, #68, #69, #74, #75, #76, #77, #80, #81, #83 and #85) as having physician orders for narcotic medications. The facility census was 87. Findings include: 1. […]