Inspection Reports for
Gonzales Healthcare Center

The facility was found deficient in ensuring residents' call lights were within reach, failing to implement a care plan intervention for a low air loss mattress for a resident with a Stage IV pressure ulcer, and improper medication storage including expired medications and food items in medication rooms.

The complaint investigation substantiated neglect of Resident #3 due to failure in providing peri-care. Resident #3 alleged neglect by CNAs being left wet and dirty. Resident #1 alleged verbal abuse by CNAs which was not reported by staff as required. The facility failed to report abuse allegations to the State Agency timely. The facility's investigation and reporting processes were deficient.

The facility was found to have failed in preventing neglect and abuse, including failure to provide peri-care to Resident #3, failure to report allegations of abuse for Resident #1, and failure to timely report abuse/neglect allegations to the State Agency. The Quality Assurance and Performance Improvement committee also failed to monitor and evaluate corrective actions effectively.

The complaint investigation substantiated verbal abuse by S4FAD (Former Activities Director) towards Resident #1. Multiple interviews confirmed the verbal abuse incident on 10/10/2024, and the administrator substantiated the finding on 11/06/2024.

The facility failed to keep a resident free from staff to resident verbal abuse and failed to ensure the activities program was directed by a qualified professional. Verbal abuse was substantiated against the former Activities Director (S4FAD) towards Resident #1, and the facility lacked documentation of S4FAD's qualifications for the position.

The complaint investigation involved allegations of neglect for Residents #1, #2, and #3. The facility failed to timely report investigation results for Residents #1 and #3 and failed to conduct thorough investigations for Residents #2 and #3. The investigation was substantiated with findings of delayed reporting and inadequate investigation procedures.

The facility failed to timely report the results of neglect investigations for Resident #1 and Resident #3 to the State Survey Agency. Additionally, the facility did not conduct thorough investigations for neglect allegations involving Resident #2 and Resident #3, including lack of valid witness statements and failure to interview Resident #3. The Quality Assurance and Performance Improvement (QAPI) committee also failed to provide evidence of ongoing monitoring and corrective actions related to incontinence care documentation.

The complaint investigation was substantiated by observations, interviews, and record reviews confirming improper securing of residents during transport, resulting in injury and safety risks.

The facility failed to properly secure residents in transportation vehicles, leading to an Immediate Jeopardy event when Resident #5's wheelchair tipped over causing a head injury, and Random Resident #6 was improperly restrained. Additionally, the facility lacked adequate administrative oversight, including incomplete vehicle logs, missing safety inspections, and insufficient driver training and competency verification.

The complaint was substantiated based on reports from an anonymous bystander and the resident's physician's office, confirming verbal abuse by the transportation driver towards Resident #1.

The facility substantiated that a transportation driver verbally abused Resident #1 by refusing to assist with paperwork and yelling at him. The driver was suspended and subsequently terminated after the investigation confirmed the abuse.

The complaint investigation involved 7 residents reviewed for abuse and/or neglect. Resident #6's investigation report was submitted late. Resident #4's neglect allegation was not thoroughly investigated, lacking staff statements and documentation. Resident #5 was left unattended and not changed for an extended period, confirmed by staff statements.

The facility failed to timely report the results of an abuse investigation for Resident #6, failed to thoroughly investigate an alleged neglect incident for Resident #4, and failed to ensure timely incontinence care for Resident #5. Deficiencies involved delayed reporting, incomplete investigations, and neglect in care provision.

The complaint investigation involved 8 sampled residents with allegations of abuse, neglect, medication errors, failure to report and investigate injuries, and infection control issues. Some allegations were substantiated, including physical abuse by residents, verbal abuse and neglect by staff, and neglect related to incontinence care.

The facility was found to have multiple deficiencies including failure to protect residents from physical and verbal abuse and neglect, failure to timely report and investigate injuries of unknown origin, failure to administer medications and treatments as ordered, failure to maintain current hospice documentation, and failure to follow infection prevention protocols such as hand hygiene during catheter care.

The visit was complaint-related due to allegations of neglect involving failure to provide timely assistance and incontinence care to multiple residents. Some allegations were substantiated, including neglect of Resident #5, while others were unsubstantiated or lacked thorough investigation.

The facility failed to ensure residents were free from neglect, including failure to provide timely assistance with toileting and incontinence care, and failed to conduct thorough investigations of neglect allegations. Several residents experienced prolonged wait times for call bell responses, resulting in actual or potential harm.

The facility failed to develop a timely fall care plan for a resident at high risk for falls, failed to provide proper incontinence care to prevent urinary tract infections for one resident, and failed to monitor and document self-catheterization care and related symptoms for another resident.

The complaint investigation involved 13 sampled residents. Specific substantiated issues included resident-to-resident abuse involving Residents #10, #11, #12, and #13; neglect related to Resident #5's incontinence care; misappropriation of funds by Resident #6 using Resident #3's credit card without permission; failure to report allegations of neglect involving Residents #4 and #10 to the state agency within 24 hours; and failure to investigate these allegations thoroughly.

The facility failed to protect residents from resident-to-resident physical abuse and neglect, failed to prevent misappropriation of resident property, and failed to timely report and investigate allegations of neglect as required by policy and regulations.

The complaint involved an allegation that an aide pushed Resident #4's head into the wall. Resident #4 reported the aide to the head nurse the morning of the incident. The facility's abuse policy required reporting within 24 hours, but the regulation requires reporting within 2 hours. The allegation was reported to the administrator on 11/30/2023 morning, and a SIMS was opened the same day at 4:53 p.m. The investigation was incomplete as the ordered x-ray was not completed and no evidence of the x-ray results or initial assessment was documented.

The facility failed to report the alleged physical abuse within the required 2-hour timeframe and did not thoroughly investigate the allegation, including failure to complete or document an ordered x-ray and initial assessment for Resident #4.

The complaint investigation focused on Resident #1 and Resident #3 regarding enteral feedings. Resident #1 showed signs of intolerance to the feeding, including nausea, bloating, and refusal of feedings. The facility did not notify the physician as required. Interviews with the Director of Nursing, Medical Director, Registered Dieticians, and Regional Registered Dietician confirmed the failure to notify and inappropriate increase in feeding volume despite intolerance.

The facility failed to immediately notify Resident #1's physician of a change in the resident's ability to tolerate enteral feeding and failed to provide appropriate treatment and services to enhance the resident's tolerance of enteral feedings. Resident #1 experienced nausea, bloating, and refusal of feedings, but the physician was not notified. The facility increased the feeding volume despite the resident's intolerance, contrary to medical recommendations.

The complaint investigation substantiated that Resident #1 was not provided timely incontinence care on 07/17/2023 despite multiple requests, and staff failed to follow proper hand hygiene protocols. Nurse staffing information was also not posted daily as required.

The facility failed to ensure timely incontinence care for residents requiring assistance, specifically Resident #1 and Resident #5, resulting in minimal harm or potential for actual harm. Additionally, the facility failed to perform proper hand hygiene practices during incontinence care and failed to post nurse staffing information daily as required.

The complaint investigation included issues of resident independence in bathroom access, abuse reporting and investigation, physician orders for care, care plan updates after falls, medication administration errors, medication storage security, and medical record accuracy.

The facility failed to provide independent bathroom access for wheelchair residents due to bed placement, failed to timely report and investigate an injury of unknown origin, failed to obtain timely physician orders for code status and device care, failed to update care plans after falls, administered medication from another resident's supply, left medication storage room unlocked, and failed to maintain accurate medical records for wounds and treatments.