Inspection Reports for Gateway Post-Acute Care Center
8600 US Hwy 19 N, Pinellas Park, FL 33782, FL, 33782
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
11.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
157% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 11
Date: Dec 10, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitation standards in the facility's kitchen and nourishment rooms.
Findings
The facility failed to maintain the kitchen and nourishment rooms in a clean and sanitary manner, with multiple observations of unlabeled and undated food, broken equipment, pest presence, and poor hygiene practices. The dishwasher was not achieving required sanitizer levels, and food storage and preparation areas were dirty and improperly maintained.
Deficiencies (11)
Kitchen and nourishment rooms were not maintained in a clean and sanitary manner; food was prepared and stored improperly.
Unlabeled and undated food items found in refrigerators and freezers.
Broken thermometer in refrigerator and missing thermometer in freezer.
Broken seals on refrigerator and freezer doors with icicles and spilled food.
Presence of gnats and live roach in kitchen and food storage areas.
Dishwasher sanitizer testing showed chemical concentration less than required 50 PPM.
Food preparation tables were corroded, rusting, and one was broken and uneven.
Food stored improperly such as milk crates on floor, unwrapped bacon, and food mixed with nonfood items.
Staff observed not performing hand hygiene and handling food with bare hands.
Two bottles of salad dressing used to prop open dry storage room door and remained on floor despite being moved.
Wires and insulation exposed on kitchen floor.
Report Facts
Dishwasher sanitizer concentration: 50
Dishwasher sanitizer concentration: <50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Dietary Aide | Observed washing dishes and performing sanitizer testing with results less than 50 PPM |
| Certified Dietary Manager | CDM | Confirmed dishwasher sanitizer levels less than 50 PPM, observed food safety violations, and did not perform hand hygiene |
| Staff B | Dietary Aide | Observed washing dishes and performing sanitizer testing with results less than 50 PPM |
| Assistant CDM | Assistant Certified Dietary Manager | Performed multiple dishwasher sanitizer tests and confirmed results reaching 50 PPM |
| Maintenance Director | Interviewed regarding exposed wires and insulation on kitchen floor | |
| Regional Maintenance Director | Interviewed regarding exposed wires and insulation on kitchen floor | |
| Assistant Dietary Director | Interviewed about food storage and cleanliness issues in kitchen |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 18, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with providing a safe, clean, comfortable, and homelike environment for residents, specifically focusing on the secured unit within the facility.
Findings
The facility failed to maintain a clean and homelike environment in the secured unit, with observations including brown substances on floors and walls, damaged ceiling tiles, broken blinds, scratched walls and doors, and missing floor tiles. Maintenance staff acknowledged these issues and planned repairs, but these concerns were not previously reported or logged.
Deficiencies (5)
Brown substance on floor and walls, white powdery substance on over-bed table in memory care unit alcove.
Uncovered dusty ceiling vent in bathroom.
Hole in wall and missing floor tiles under sink in bathroom.
Missing transition between bathroom and room.
Secured unit dayroom ceiling tiles pushed up and not flush, broken and pulled apart blinds, scratched walls, cracked wall near locked storage closet, scratched and paint-missing main door.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Director of Maintenance | Stated that blinds were changed and acknowledged maintenance issues. |
| Staff I | Maintenance Worker | Confirmed replacement of blinds in secured unit dayroom. |
| Staff J | Director of Maintenance | Acknowledged ceiling tile and wall repairs needed, confirmed door condition and repair plans. |
Inspection Report
Routine
Deficiencies: 12
Date: Mar 18, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident rights, care planning, infection control, medication administration, activities, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to honor resident preferences for name usage, inadequate care planning for dental and vision needs, insufficient activities and activity space for memory care residents, medication errors exceeding 5%, improper medication storage and labeling, ineffective infection control practices including PPE use and hand hygiene, malfunctioning dishwashing machine with improper sanitizing levels, unsecured handrails posing safety hazards, and an ineffective pest control program with observed insect infestations.
Deficiencies (12)
Failed to honor resident #169's preferred name usage and dignity.
Failed to maintain clean clothing for resident #80 and ensure proper hygiene.
Failed to ensure correct spelling or display of resident names on doors for residents #70 and #102.
Failed to coordinate assessments with PASRR program and update PASRR screenings for multiple residents (#5, #7, #13, #14, #20, #50, #53, #54, #65, #70, #80, #88, #170).
Failed to develop and implement comprehensive care plans addressing dental and vision needs for residents #98 and #100.
Failed to provide adequate activities and activity space for 52 residents on memory care unit.
Medication error rate of 18.52% with five errors out of 27 medication administration opportunities observed for residents #57, #83, #7, #76, and #98.
Failed to ensure medication carts and treatment carts were locked and medications stored properly; medications stored with cleaning materials; expired and undated medications observed.
Failed to implement infection prevention and control program including PPE use for resident #80 on droplet precautions, cleanable mattress for resident #95, and hand hygiene for staff and residents.
Dishwashing machine failed to meet required wash and rinse temperatures and sanitizer levels were above acceptable ranges on multiple days.
Unsecured and broken handrails on South-Memory Care unit posed safety hazards.
Ineffective pest control program with multiple observations of flying insects and cockroach in kitchen and resident areas.
Report Facts
Medication error rate: 18.52
Medication administration opportunities observed: 27
Medication errors observed: 5
Residents affected by medication errors: 5
Memory care residents: 52
Dishwashing machine sanitizer ppm: 200
Dishwashing machine wash temperature: 117
Dishwashing machine rinse temperature: 119
Handrail audit date: Mar 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Observed leaving medication cart unlocked; involved in medication administration. |
| Staff G | Licensed Practical Nurse/Unit Manager (LPN/UM) | Informed staff about resident #80's COVID precautions; involved in medication administration and training. |
| Staff N | Registered Nurse (RN) | Observed administering late medications to residents #57 and #83. |
| Staff D | Dietary Aide | Operated dishwashing machine; demonstrated machine use; confirmed sanitizer ppm too high. |
| Staff C | Dietary Manager | Provided dishwashing machine temperature logs; interviewed about machine operation and maintenance. |
| Staff B | Dietary Aide | Observed wrapping parfait dishes with bare hands and handling earbuds without hand hygiene. |
| Staff Q | Licensed Practical Nurse (LPN) | Observed administering insulin pen incorrectly to resident #98. |
| Staff J | Director of Maintenance | Interviewed about unsecured handrails and pest control reporting. |
| Staff H | Pest Management | Interviewed about pest control services and recent pest activity. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding PASRR, medication errors, infection control, and maintenance issues. |
| Staff F | Certified Nursing Assistant (CNA) | Interviewed about hand hygiene and resident care. |
| Staff M | Patient Care Assistant (PCA) | Observed sitting without interaction with residents in memory care unit. |
| Staff L | Certified Nursing Assistant (CNA) | Reported staff do not document specific activities but document resident participation. |
| Staff X | Licensed Practical Nurse (LPN), MDS Coordinator | Reported completing MDS sections and screening residents but unaware of dental and vision needs for residents #98 and #100. |
| Staff W | Social Service | Reported not aware of vision and dental status for residents #98 and #100. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jul 11, 2023
Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to provide a safe, clean, and homelike environment, and a failure to timely report suspected abuse and theft.
Complaint Details
The complaint investigation included review of an incident where a 30-day supply of Klonopin was missing from the medication cart and was not reported to law enforcement. Interviews with staff and review of policies revealed failures in reporting and maintenance of a safe environment. Law enforcement confirmed no report was received regarding the incident.
Findings
The facility was found to have multiple environmental deficiencies including furniture and walls in disrepair, soiled resident equipment, stained and damaged flooring, and inadequate cleaning protocols. Additionally, the facility failed to report a reasonable suspicion of a crime to law enforcement after a controlled substance was found missing.
Deficiencies (8)
Furniture in resident rooms had missing knobs, mismatched drawers, deteriorated particle board, and warped surfaces.
Walls in multiple rooms and common areas contained patched areas, cracks, holes, and missing corner guards.
Wheelchairs and resident equipment were heavily soiled and in disrepair, with exposed foam and peeling coatings.
Bathrooms had missing toilet paper holder rods, broken tiles, stained floors, and de-silvering mirrors.
Day rooms contained damaged walls, rusted furniture, and plumbing concealment boxes.
Ceiling air vent contained condensation and black biological growth.
Mechanical lift was uncovered and dirty with hair spun around wheels.
Facility failed to report a reasonable suspicion of a crime to law enforcement after a 30-day supply of Klonopin was found missing and not entered on the controlled substance inventory list.
Report Facts
Deficiencies cited: 8
Medication missing: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Nurse who received the missing medication from the pharmacy |
| Staff I | Housekeeper and Certified Nursing Assistant (CNA) | Reported cleaning protocols and maintenance reporting |
| Staff F | Certified Nursing Assistant (CNA) | Reported maintenance concerns and furniture conditions |
| Nursing Home Administrator (NHA) | Interviewed regarding environmental concerns and reporting procedures | |
| Director of Maintenance/Environmental Services | Interviewed regarding maintenance practices and furniture replacement | |
| Housekeeping Manager | Interviewed regarding cleaning processes and quality assurance | |
| Director of Nursing (DON) | Responsible for reporting to law enforcement according to former NHA |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 23, 2023
Visit Reason
The inspection was conducted as an annual survey of Gateway Post-Acute and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected were reported as unknown.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Dec 16, 2021
Visit Reason
The inspection was conducted as part of the annual survey of Gateway Post-Acute and Rehabilitation Center to assess compliance with regulatory requirements related to resident dignity, safety, care planning, discharge planning, smoking policies, and equipment maintenance.
Findings
The facility was found deficient in maintaining resident dignity and respect, timely reporting of an elopement incident, developing care plans for isolation precautions, timely discharge planning, securing resident smoking materials, and ensuring proper maintenance of a walk-in freezer. Several residents lacked personal effects and appropriate clothing, an elopement was not reported timely, isolation precautions were not care planned, discharge was delayed due to Medicaid application processing, smoking materials were improperly secured, and the freezer had heavy ice buildup.
Deficiencies (6)
Failure to ensure dignity was maintained for residents on one unit related to lack of furnishings such as pillows, blankets, and personal effects, and failure to ensure fitted clothing for one resident.
Failure to timely report an alleged allegation of neglect related to an elopement to regulatory agencies for one resident.
Failure to develop and implement a complete care plan related to Isolation Precautions for one resident.
Failure to provide a timely discharge for one resident resulting in increased anxiety and medication use due to delays in Medicaid application processing.
Failure to ensure resident smoking materials were secured for seven residents who smoked independently, contrary to facility policy.
Failure to keep one walk-in freezer free from ice blocking and heavy frosting, posing a risk to food safety.
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 7
Days observed: 4
Temperature: -13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Registered Nurse/Unit Manager (RN/UM) | Named in findings related to resident dignity and clothing deficiencies |
| Director of Nursing (DON) | Director of Nursing | Named in findings related to resident dignity, clothing, elopement incident, and discharge planning |
| Staff G | Certified Nurse Assistant (CNA) | Named in findings related to resident dignity and pillow provision |
| Regional Director Clinical Service | Regional Director Clinical Service | Named in findings related to resident clothing and belts |
| Staff Z | Agency Certified Nursing Assistant (CNA) | Named in elopement incident |
| Staff Y | Social Services | Named in elopement incident and discharge planning |
| Staff X | Licensed Practical Nurse (LPN) | Named in elopement incident |
| Staff W | Certified Nursing Assistant (CNA) | Named in elopement incident |
| Staff U | Licensed Practical Nurse (LPN) | Named in elopement incident |
| Staff D | Certified Nursing Assistant (CNA) | Named in elopement incident and smoking materials findings |
| Staff R | Certified Nursing Assistant (CNA) | Named in elopement incident |
| Staff S | 3-11p.m. Supervisor | Named in elopement incident |
| Staff E | Registered Nurse (RN) and evening supervisor | Named in smoking materials findings |
| Staff F | Staffing Coordinator | Named in smoking materials findings |
| Nursing Home Administrator (NHA) | Nursing Home Administrator | Named in smoking materials and freezer maintenance findings |
| Maintenance Director | Maintenance Director | Named in freezer maintenance findings |
| Staff Y | Social Services | Named in discharge planning |
| Admissions Director | Admissions Director | Named in discharge planning |
| Director of Rehab | Director of Rehab | Named in discharge planning |
| Staff Q | Doctor of Physical Therapy (DPT) | Named in discharge planning |
Inspection Report
Routine
Deficiencies: 5
Date: Oct 7, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, care planning, medication management, staffing information posting, and environmental conditions.
Findings
The facility was found to have multiple deficiencies including unclean and disrepair conditions in resident rooms and common areas, failure to implement a care plan for a resident at risk for falls, improper tube feeding administration, failure to post daily nurse staffing information, and improper labeling and disposal of medications.
Deficiencies (5)
Resident rooms and other spaces in two units were not clean and free from disrepair, including dusty air conditioner filters, dirty ceiling vents, peeling walls with biogrowth, unsecured screws accessible to residents, and unsanitary conditions in shower rooms and common areas.
Failure to implement a care plan for Resident #88 related to supervision for frequent falls, resulting in multiple falls without proper supervision or appropriate footwear.
Resident #94 did not receive tube feeding in accordance with physician orders on two of four days observed, including delayed start and incorrect flow rate of feeding.
Facility failed to post required daily nurse staffing information showing census, licensed and unlicensed staff, and actual hours worked for each shift.
Medications on two medication carts were improperly labeled or expired, including ophthalmology solutions and inhalers that were undated or past discard dates.
Report Facts
Deficiencies cited: 5
Falls: 3
Tube feeding flow rate: 65
Tube feeding flow rate observed: 55
Tube feeding flow rate corrected: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Housekeeper | Observed using a dirty mop bucket on the secured south unit |
| Staff M | Certified Nursing Assistant (CNA) | Reported no showers given on Sundays and confirmed trash conditions in shower room |
| Assistant Director of Nursing (ADON) | Provided observations and statements regarding facility conditions and care issues | |
| Maintenance Director | Observed and confirmed safety issues with wallboard and screws in resident rooms | |
| Unit Manager | Confirmed observations and care plan implementation issues for Resident #88 and tube feeding issues for Resident #94 | |
| Nurse Q | Nurse | Reported Resident #88 laughing after fall and assisted resident |
| Nurse E | Nurse | Hooked up tube feeding for Resident #94 late and unaware of feeding start time |
| Registered Dietitian | Provided input on tube feeding flow rate and nursing responsibilities | |
| Nursing Home Administrator | Confirmed staffing posting deficiencies and provided policy documents | |
| Staff Member K | Licensed Practical Nurse/Nurse Supervisor (LPN) | Observed expired and unlabeled medications on medication carts |
| Staff Member J | Licensed Practical Nurse (LPN) | Observed medication cart with expired and unlabeled medications |
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