Gonzales Healthcare Center

In the surveyor’s words

From the most serious findings on record at Gonzales Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Sep 5, 2024

  Based on observation, interview, and record review, the facility failed to properly secure residents in the facility's transportation vehicles for 2 (Resident #5 and Random Resident #6) of 2 (Resident #5 and Random Resident #6) sampled residents reviewed for accident hazards. This deficient practice resulted in an Immediate Jeopardy situation on 08/22/2024 at 11:47 a.m. for Resident #5 when S6Driver failed to properly secure the resident in a forward facing direction in the facility's transportation bus, Resident #5's wheelchair tipped over backwards during transport, and caused Resident #5 to strike the back of her head. Resident #5 was transported to the hospital where she was assessed as having an abrasion to the back of the head and had to receive pain medication. […]

• Immediate jeopardy, widespreadF835Sep 5, 2024

  Based on observations, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently by failing to have an adequate system in place to ensure residents were properly restrained in the facility's transportation vehicles, vehicle transportation logs were completed as required for the facility's transportation vehicles, and the facility's transportation drivers were competent on the use of the facility's van and bus restraint systems prior to transporting residents. This lack of administrative oversight resulted in an Immediate Jeopardy situation on 08/22/2024 at 11:47 a.m. […]

• Actual harm, isolatedF600Mar 14, 2024

  Based on record reviews and interviews, the facility failed to ensure a resident remained free from neglect and psychosocial harm when nursing staff failed to provide care and services to a newly admitted resident for 1 (Resident #5) of 19 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19) reviewed for neglect. This deficient practice resulted in actual harm on 02/08/2024 at 10:00 p.m. when S6Licensed Practical Nurse (LPN) and S7Certified Nursing Assistant (CNA) both arrived to work at 10:00 p.m. […]

• No harm, potential for more than minimal, patternF761May 7, 2025

  Based on observations and interviews the facility failed to: 1. ensure expired medications were not available for resident use on 2 (Medication Cart c, Medication Cart e) of 2 (Medication Cart c, Medication Cart e) medication carts observed; 2. ensure expired medications were not available for resident use in 2 (Medication Room h, Medication Room g) of 2 (Medication Room h, Medication Room g) medication rooms observed; and, 3. ensure food items were not stored in the medication room for 1 (Medication Room g) of 2 (Medication Room h, Medication Room g). […]

• No harm, potential for more than minimal, patternF600May 16, 2024

  Based on record reviews and interviews, the facility failed to: 1. Protect a resident's right to be free from physical abuse by Resident #239 for 1 (Resident #75) of 8 (Resident #11, Resident #37, Resident #43, Resident #47, Resident #75, Resident #239, Resident #20, and Resident #23) sampled residents investigated for abuse and neglect; 2. Protect a resident's right to be free from physical abuse by Resident #43 and Resident #47 for 2 (Resident #43 and Resident #47) of 8 (Resident #11, Resident #37, Resident #43, Resident #47, Resident #75, Resident #239, Resident #20, and Resident #23) sampled residents investigated for abuse and neglect; 3. […]