Gilpin Hall

In the surveyor’s words

From the most serious findings on record at Gilpin Hall, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 28, 2022

  Based on interview and record review it was determined that for three (R1, R2, and R4) out of four residents reviewed for accidents, the facility failed to ensure supervision to prevent accidents. For R1 the plan of care was not followed resulting in an accident that led to R1's severe adverse outcome, death. This was identified as an IJ on [DATE] at 12:20 PM and abated on [DATE] at 8:00 AM. For R2 the facility failed to provide the appropriate supervision to prevent a fall with injury requiring a transfer to the ER and two staples to the head, R2 sustained harm. R4 was left unattended and fell from a shower chair resulting in a broken arm, R4 was harmed. Findings include: 1. […]

• Actual harm, isolatedF689Jul 14, 2026

  Based on record review and interview it was determined that for one (R4) out of four residents reviewed for accidents the facility failed to provide assistive devices to prevent an accident. R4 was transported in a facility vehicle without all safety straps secured. The facility driver came to a sudden stop and R4 fell forward and acquired two broken legs causing physical harm. The facility was found to be in past noncompliance with correction completed as of 1/8/26. Findings include:Review of R4's clinical record revealed:12/3/25 - An annual MDS assessment documented that R4 was cognitively intact and required substantial maximum assistance with upper body dressing and weighed 265 pounds.12/7/25 - R4's care plan for self-care deficit included the intervention for staff to provide… […]

• No harm, potential for more than minimal, widespreadF801Aug 3, 2021

  Based on observations and interview, it was determined that the facility failed to provide qualified dietary managerial staff to oversee food safety practices during all times of the kitchen operation. Findings include: During the initial kitchen tour on 7/19/21 from 8:00 AM to 9:45 AM, it was revealed that there were no individuals on premise with current Certified Food Protection Manager training. Finding was reviewed and confirmed with E1 (NHA) on 7/21/2021 at approximately 11:30 AM.

• No harm, potential for more than minimal, widespreadF812Aug 3, 2021

  Based on observations and interview it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: The following findings were made during the observation of the initial kitchen tour on [DATE] from 8:00 AM to 9:45 AM: - A spoon was left in the hand washing sink next to the dish washing station; - Non-Cleanable surfaces such as paper were used as shelving in the walk-in refrigerator. The usage of non-cleanable material traps moisture and microbes; - Observed expired yogurt in the walk-in refrigerator; - There were unlabeled foods (pork and eggs) left uncovered in the reach in refrigerator; - Observed dead insect parts lodged in the fume hood. […]

• No harm, potential for more than minimal, patternF570Aug 29, 2025

  Based on record review and interview, it was determined that the facility failed to have a surety bond that covered the current balance in the residents' trust accounts ($28,733.79). Findings include:8/27/25 10:15 AM - The facility provided the surveyor with a copy of the facility's surety bond from [insurance company] in the amount of $20,000 with a term of 12/08/24 to 12/08/25. 8/27/25 10:18 AM - The facility provided the surveyor a list labelled Trust- Current Account Balance as of 8/27/25. The list named forty-five facility residents with personal funds accounts managed by the facility. The Client Account Summary stated that there was $28,733.79 currently in the account. […]