Inspection Report
Renewal
Census: 25
Capacity: 58
Deficiencies: 8
Jan 28, 2025
Visit Reason
The inspection was conducted as a renewal licensing study for The Gilbert Residence to assess compliance with regulatory requirements and determine eligibility for license renewal.
Findings
The facility was found to be non-compliant with multiple rules including employee health screening timelines, staff training documentation, medication administration records, meal menu postings, meal and food record keeping, water temperature regulation, and kitchen sanitation logs. Several violations were repeat from prior reports.
Deficiencies (8)
| Description |
|---|
| Employee 6's tuberculosis test was not administered within the required timeline and the facility lacked a completed TB Risk Assessment. |
| The staff schedule lacked designation of a supervisor of resident care for each shift. |
| No documented evidence of completed staff training on reporting, personal care, dementia, and fire prevention. |
| Medication administration records for several residents lacked specified reasons for as-needed medications. |
| No pureed diet menu was available or posted despite residents being prescribed pureed diets. |
| The home did not maintain a record of the meal census including residents, personnel, and visitors served. |
| Hot water temperature in memory care apartment 106 was 129.4°F, exceeding the regulated range. |
| Dish machine temperature and pot-sink sanitizer concentration logs had multiple blank entries for January 2025 meals. |
Report Facts
Number of staff interviewed and/or observed: 15
Number of residents interviewed and/or observed: 25
Facility capacity: 58
Water temperature: 129.4
Dish machine temperature log missing entries: 5
Pot-sink sanitizer concentration log missing entries: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Derek McGill | Administrator/Authorized Representative | Named as facility administrator and authorized representative |
| Jessica Rogers | Licensing Staff | Licensing consultant who signed the report |
Inspection Report
Renewal
Deficiencies: 0
Jan 12, 2024
Visit Reason
The document serves as an administrative review and notification of license renewal for The Gilbert Residence, confirming substantial compliance with public health code and administrative rules for home for the aged facilities over the past year.
Findings
The facility demonstrated substantial compliance with applicable public health codes and administrative rules regulating home for the aged facilities, supporting the renewal of its license upon receipt of the licensing bed fee.
Inspection Report
Renewal
Census: 35
Capacity: 58
Deficiencies: 6
Dec 15, 2022
Visit Reason
The inspection was conducted as a renewal licensing study for The Gilbert Residence to assess compliance with applicable rules and regulations.
Findings
The facility was found to be non-compliant with several rules including employee tuberculosis screening, medication administration documentation, resident service plan adequacy, therapeutic diet menu posting, and dish sanitization record keeping. A corrective action plan is required for license renewal.
Deficiencies (6)
| Description |
|---|
| Employee #1’s file lacked evidence of tuberculosis screening within 10 days of hire and before occupational exposure; annual TB risk assessment was not conducted or maintained. |
| Resident A’s medication administration records had multiple dates with blank doses in November and December 2022. |
| Resident B’s medication administration records had blank doses on two dates in December 2022. |
| Resident service plans lacked sufficient instructions on medication supervision and behavior indicators for agitation. |
| Therapeutic or special diet menus were not available or posted as required. |
| December 2022 dish sanitization records were left blank, preventing confirmation of proper sanitization. |
Report Facts
Number of residents interviewed and/or observed: 35
Facility capacity: 58
Number of staff interviewed and/or observed: 14
Dates with blank medication doses for Resident A: 10
Dates with blank medication doses for Resident B: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Rogers | Licensing Consultant | Author of the report and recommendation |
Inspection Report
Original Licensing
Capacity: 58
Deficiencies: 0
Dec 5, 2013
Visit Reason
The visit was conducted to approve resident use of the facility's newly renovated 'Main Street' area, which was formerly the Grace Hall dementia care unit.
Findings
The renovated area, named 'Main Street,' includes multiple common-use rooms such as a park-scape room, wellness center, library, billiard room, movie theater, bistro café, and a barrier-free toilet room. The area was found to be in full compliance with Home for the Aged rules and was approved for resident use.
Report Facts
Facility capacity: 58
Project approval date: Nov 18, 2013
Occupancy approval date: Nov 19, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Derek McGill | Administrator and Authorized Representative | Notified licensing staff about renovation during inspection |
| Patricia J. Sjo | Licensing Staff | Conducted inspection and authored report |
| Betsy Montgomery | Area Manager | Approved the report |
Inspection Report
Original Licensing
Capacity: 58
Deficiencies: 0
May 30, 2013
Visit Reason
The visit was conducted as an original licensing study addendum to increase the licensed capacity from 40 beds to 58 beds due to a newly constructed dementia care unit.
Findings
The inspection found the facility in full compliance with an acceptable dementia program statement and approved the new dementia care unit. Occupancy approval was pending final BFS and HFES approvals, which were later received, allowing the license capacity increase to 58 beds.
Report Facts
Licensed capacity: 58
Building addition size (square feet): 14300
Existing beds: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Derek McGill | Administrator/Authorized Representative | Interviewed during inspection and involved in licensing process |
| Patricia J. Sjo | Licensing Staff | Conducted inspection and authored report |
| Betsy Montgomery | Area Manager | Signed recommendations for license increase |
| Laura Pettit | Sanitarian | Conducted HFES plan reviews and communicated occupancy approval status |
Inspection Report
Renewal
Capacity: 40
Deficiencies: 0
Aug 23, 2007
Visit Reason
The visit was a renewal inspection conducted to review the facility's modification request to add services for residents with Alzheimer's disease and other forms of dementia.
Findings
The inspection found that the facility's Grace Hall, a 10-bed unit for residents with Alzheimer's or related dementia, met all compliance requirements including staff training, safety approvals, and service descriptions. The unit doors are locked to prevent wandering, and activities and meals are provided within the unit.
Report Facts
Capacity: 40
Bed count: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrea Krausmann | Licensing Staff | Author of the inspection report and recommendation |
| Mary Jo Gibbons | Authorized Representative and Administrator | Facility representative who requested modification of license terms |
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