Gordon Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Gordon Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF658Apr 1, 2026

  Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration-General, and Insulin Administration Policy, the facility failed to maintain professional standards of practice for three medication observations from a total of 33 medications observed. Specifically, the facility failed by signing that medication was administered but not due until the following day and failed to accurately administer insulin from a pen device. This deficient practice increased the risk of adverse clinical outcomes. Findings include: Review of the facility's policy titled Insulin Administration, dated 12/31/2025, documented the following guidelines for insulin pen administration: .10. […]

• No harm, potential for more than minimal, isolatedF759Apr 1, 2026

  Based on observations, staff interviews, record review, and policy review, the facility failed to ensure a medication error rate of less than five percent during medication administration review. Four errors were identified from 33 opportunities, resulting in a 12 percent (%) medication error rate. The deficient practice placed residents at risk for inaccurate dosing and adverse clinical outcomes.Findings include:Review of the facility's policy titled Insulin Administration, dated 12/31/2025, documented the following guidelines for insulin pen administration: .10. Inject the insulin by quickly inserting the needle straight in at a 90-degree angle per manufacturer instruction.11. Use your thumb to press down on the dose knob until it stops.12. […]

• No harm, potential for more than minimal, isolatedF880Apr 1, 2026

  Based on observations, staff interviews, and review of the facility's policy titled Standard Precaution/ Use of Personal Protective Equipment (PPE), the facility failed to ensure medications were prepared and administered using appropriate infection control practices and safe medication handling techniques to prevent contamination for two residents (R) (R20 and R21) of three residents observed during a medication pass. This deficient practice increased the risk of cross contamination and spread of infection to residents and staff.Findings include:Review of the facility's policy titled Standard Precautions/Use of PPE, last reviewed 12/27/2025, documented the following guideline for hand hygiene: During the delivery of healthcare, avoid unnecessary touching of surfaces near the patient to… […]

• No harm, potential for more than minimal, isolatedF645Apr 13, 2025

  Based on staff interviews, record review, and review of the facility policy titled, Mental Wellness Services, the facility failed to perform a Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of 41 sampled residents (R) (R108) reviewed. This failure had the potential for residents with mental disorders not to receive identified specialized services. Findings include: A review of the facility policy titled Mental Wellness Community last reviewed 12/27/2024 revealed under Guideline: Patients living on the community should have appropriate level 1's completed as required to determine whether a new level 2 is needed. […]

• No harm, potential for more than minimal, isolatedF880Apr 13, 2025

  Based on observations, staff interviews, record review, and review of the facility's policies titled, Transmission-Based Precautions (Contact, Enhanced Barrier, Droplet, Airborne) and Hand Hygiene, the facility failed to ensure infection control processes were followed during a dressing change for one of 13 residents (R) (R12) on enhanced barrier precautions (EBP). This deficient practice created the potential for the spread of infections in the facility. Findings include: Review of the facility's policy titled, Transmission-Based Precautions (Contact, Enhanced Barrier, Droplet, Airborne), dated 12/27/2024, revealed the Enhanced Barrier Precautions (EBP), section included, Enhanced Barrier Precautions are indicated for patients with any of the following: . […]