Gottlieb Memorial Hospital

In the surveyor’s words

From the most serious findings on record at Gottlieb Memorial Hospital, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Nov 10, 2021

  Based on observation, interview, and record review, the facility failed to perform deep cleaning to prevent pest infestation, maintain clean and sanitized foodservice equipment, store food in a manner that prevented contamination, utilize chemical sanitizing solution per manufacturer's instructions, and perform proper hand hygiene before/after touching food. This applies to all 15 residents receiving oral diets at the facility. The findings include: Facility document Alphabetical List of All Residents, dated 11/7/21, shows there were 15 residents in the facility. Facility document NPO (Not By Mouth) Patients, dated 11/7/21, shows there were no residents in the facility that had physician diet orders of NPO. 1. […]

• No harm, potential for more than minimal, patternF803Mar 12, 2026

  Based on interview and record review, the facility failed to plan and serve menu items per facility menu planning standards. This applies to 6 of 6 residents (R27, R35, R36, R39, R40, R41) reviewed for menu planning in a sample of 8.The findings include:Review of Room Service Diet reports, dated 3/9/26, show R35, R36, R39, R40, and R41 all had physician orders for Regular Diets. Physician order, dated 2/28/26, shows R27 had a physician order for a pureed diet. On 3/10/26 at 1:04 PM, V7 (Regional Clinical Nutrition Manager/ Registered Dietitian) stated the menus should contain 6 serving a day of whole or enriched grains including bread, cereal, dry cereal, rice, buns, tortillas, desserts. V7 stated she did not consider potatoes as a grain serving. […]

• No harm, potential for more than minimal, patternF684Nov 10, 2021

  Based on observation, interview and record review, the facility failed to follow standard professional practices by not implementing its policy and practices for hand hygiene and gloves usage during medication administration and wound care. This applies to 4 of 7 residents (R6, R67, R68 and R166) reviewed for quality of care during wound care and medication administration in a total sample of 8. The findings include 1. On 11/07/21 at 12:14 P.M., V17 (RN/Registered Nurse) administered 2 units of Insulin subcutaneously via injection into R68's right side of the abdominal area. Prior to administering the insulin injection, V17 did not perform hand hygiene, and proceeded to touch computer keys, then lifted R68's shirt and injected the Insulin. […]

• No harm, potential for more than minimal, patternF804Nov 10, 2021

  Based on observation and interview the facility failed to provide food palatable for the resident. This applies to 5 of 7 residents (R116, R6, R117, R118, R119) reviewed for food palatability in a total sample of 8 residents. The findings include: 1. On 1/07/21 at 10:06 AM, R116 said the Food tastes terrible. R116 said there weren't a lot of choices of food that taste good. 2. On 11/07/21 at 10:16 AM, R6 said the food did not taste very good and was very bland. On 11/08/21 at 02:21 PM, R6 said for lunch he had tomato soup and the macaroni and cheese. R6 said the macaroni and cheese didn't taste like anything, I'm not sure what kind of cheese it was supposed to be. R6 said he placed the macaroni and cheese into his tomato soup and was able to eat it that way. 3. […]

• No harm, potential for more than minimal, isolatedF609Mar 7, 2024

  Based on interview and record review, the facility staff failed to immediately report an allegation of abuse to the abuse task coordinator. This applies to 1 of 12 residents (R62) reviewed for abuse in the sample of 12. The findings include: The EMR (Electronic Medical Record) showed that R62, a [AGE] year-old was admitted to the facility on [DATE] from the acute setting of the hospital. R62 had a recent abdominal surgery to repair hernia on 2/17/2024. R62 has other diagnoses that included gout, hypertension, chronic kidney disease, gastric bypass, and morbid obesity. The MDS (Minimum Data Set) dated 3/3/2024 showed R62 was cognitively intact with BIMS (Brief Interview Mental Status) score of 15/15. On 3/04/2024 at 10:18 A.M., R62 was sitting in a lounge chair in her room. […]