Gabriel Manor Assisted Living Center

The facility failed to ensure medications were administered as ordered, resulting in a 15% medication error rate. Specifically, staff administered an unlabeled eye drop bottle to a resident without being able to verify the medication name, strength, or expiration date.

The facility failed to ensure medications were administered as ordered, resulting in a 15% medication error rate. Specifically, staff administered unlabeled eye drops to Resident #7, making it impossible to verify the medication name, strength, or expiration date.

The facility failed to ensure that housekeeping duties performed by personal care aides between 7:00 a.m. and 9:00 p.m. were limited to non-routine tasks. Specifically, staff were observed performing routine tasks such as setting dining room tables and completing resident laundry on a scheduled basis during these hours.

The facility failed to provide appropriate snacks between meals for all residents as required by regulation. Specifically, the daily menu did not list specific snack foods or beverages for various diets, and the cook stated that dietary staff did not offer snacks to residents.

The facility failed to ensure that exit doors in the memory care unit were equipped with sounding devices that activate when opened. This lack of alarm resulted in two residents exiting the memory care unit without staff awareness.

The facility failed to ensure the safety of a resident with dementia and wandering tendencies, as evidenced by an incident on 3/4/16 where the resident exited the building unnoticed. Staff were unaware the resident had left the unit until they were observed walking outside by an RN, and alarms failed to alert personnel to the exit.

The facility failed to report known allegations of resident exploitation by a staff member to the Health Care Personnel Registry. Specifically, the facility did not report an incident where an individual attempted to use a resident's identity and social security number to apply for credit cards via a facility computer.

The facility failed to report known allegations of resident exploitation by a staff member to the Health Care Personnel Registry. An investigation revealed that credit card applications were fraudulently submitted using a resident's identity and were traced back to the facility's computer. Although the specific staff member was cleared by a lie detector test, the facility did not comply with reporting requirements regarding the incident.