The Gilbert Residence

In the surveyor’s words

From the most serious findings on record at The Gilbert Residence, in the surveyor’s own words.

• Actual harm, isolatedF689May 12, 2021

  Based on observation, interview and record review the facility failed to implement care planned interventions and physician orders to prevent falls in 1 of 1 sampled residents (R175) assessed for falls, resulting in R175 fall with fracture during staff assisted transfer requiring hospitalization and surgical repair. Findings include: Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], reflected R175 was a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included [CONDITION(S)] (affecting left non-dominant side), [CONDITION(S)], [CONDITION(S)] with use of catheter and vitamin deficiency. […]

• No harm, potential for more than minimal, widespreadF812Oct 7, 2025

  Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: On 10/06/2025 at 09:00 a.m. during an initial tour of food services was conducted with Certified Dietary Manager (CDM) “E”, the following items were observed: Cooler was observed to have red substance on the back wall and on the floor-CDM “E” explained that it was possibly spilt Jello from the weekend. Freezer was observed to have two individual containers of ice cream on the floor. […]

• No harm, potential for more than minimal, widespreadF812Oct 24, 2024

  Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean food service equipment (toaster), (2) ensure proper sanitizer concentration within the 3-compartment sink, and (3) effectively date mark all potentially hazardous ready-to-eat food products effecting 30 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, improper three-compartment sink sanitization, and resident foodborne illness. Findings include: On 10/22/24 at 09:45 A.M., An initial tour of the food service was conducted with Dietary Manager E. The following items were noted: One gallon of Country Fresh 2% milk (3/4 full) was observed within the 2-door reach-in cooler, without an effective discard date. […]

• No harm, potential for more than minimal, widespreadF812Sep 28, 2023

  Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 29 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 09/25/23 at 02:30 P.M., An initial tour of the food service was conducted with Director of Food Services C. The following items were noted: The interior and exterior surfaces of the South Bend convection ovens were observed soiled with accumulated and encrusted food residue. The exterior surfaces of the South Bend stove/ovens were observed soiled with accumulated and encrusted food residue. The [NAME] Silex commercial toaster was observed soiled with accumulated and encrusted food residue. […]

• No harm, potential for more than minimal, widespreadF812Aug 11, 2022

  Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and sanitize food service equipment, and (2) effectively date mark all potentially hazardous ready-to-eat food products effecting 24 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 08/09/22 at 11:15 A.M., An initial tour of the food service was conducted with Director of Food Services I. The following items were noted: One 5-pound container of [NAME] Food Service (GFS) Cottage Cheese was observed within the 2-door reach-in cooler with an open date of 7/22/22 and an out date of 8/14/22. […]