Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gainesville Nursing during CMS and state inspections, most recent first.
A nurse with a known history of medication diversion repeatedly accessed the I-STAT automated dispensing cabinet to withdraw oxycodone, hydrocodone-APAP, and tramadol tablets under the names of ten residents with PRN pain orders, including individuals with conditions such as MS, COPD, dementia, Parkinson’s disease, cancer, heart failure, stroke, and recent amputation. These controlled substances were not documented as administered on the MAR or in the EHR, resulting in 19 unaccounted-for narcotic tablets. Staff interviews confirmed that narcotics were supposed to be double-locked, counted each shift, and signed out on both the narcotic log and MAR, and that missing narcotics constituted misappropriation. The DON, who knew of the nurse’s prior diversion history and had instructed the nurse not to administer narcotics, had been relying on I-STAT discrepancy and monthly narcotic counts, which did not reveal the pattern because cabinet counts remained correct. A later comparison of I-STAT withdrawals by nurse name against MAR and narcotic logs exposed the misappropriation of resident medications.
A staff member in environmental services obtained a cognitively intact resident’s debit card and PIN under the pretense of helping with cash withdrawals and shopping, then conducted multiple unauthorized ATM withdrawals and Venmo transfers for personal use. Bank statements showed extra withdrawals and electronic payments beyond the amounts the resident requested, leading to overdraft fees and an insufficient funds notice. The resident reported never authorizing these additional transactions or the use of Venmo. Multiple staff, including CNAs, a CMT, an LPN, SSD, Activity Director, BOM, DON, and the Administrator, stated that only designated administrative and activities staff were allowed to shop for residents, that no staff were permitted to take residents’ debit or credit cards or accept money from residents, and that using a resident’s funds for personal purposes was misappropriation. Despite these policies and staff awareness, the employee used the resident’s card and funds for personal financial gain.
A deficiency was identified due to the failure to timely report suspected abuse, neglect, or theft, and to report the investigation results to the proper authorities. The incident was noted during a survey, but specific details about the individuals involved or the nature of the incident are not provided.
The facility failed to provide palatable meals, with residents reporting cold, flavorless, and tough food. Observations confirmed food temperatures below acceptable levels, and the Dietary Manager acknowledged the issue. Residents expressed dissatisfaction with meal quality and menu inconsistencies.
A facility failed to report an allegation of neglect to the state agency within the required timeframe. A visitor accused the Administrator of neglecting a resident, who had significant weight loss and appeared unkempt. Despite the facility's policy requiring immediate reporting of such allegations, the Administrator did not report the incident, leading to a deficiency.
A facility failed to investigate an allegation of neglect when a visitor accused the Administrator of allowing a resident to lie in bed and die. The resident, who had severe dementia and required assistance with daily activities, was observed by the visitor to have lost significant weight and appeared unkempt. Despite staff acknowledging such claims as potential neglect, the Administrator did not initiate a full investigation or report the incident to the State Survey Agency.
The facility failed to develop complete care plans for two residents, one requiring side rails for mobility assistance and another at risk for elopement due to Alzheimer's. The use of side rails was not included in the care plan despite consent and ongoing use, while the elopement risk was not addressed despite documented wandering behavior. These omissions were confirmed by the MDS Coordinator and DON.
A resident with severe cognitive impairment and dementia repeatedly attempted to elope from the facility, exhibiting combative behavior. Despite being identified as an elopement risk, the facility failed to update the care plan with new interventions or conduct a root cause analysis. Staff interventions were ineffective, and the issue was not addressed in Quality Assurance meetings.
A resident with specific dietary needs was served a whole pork chop instead of having the meat cut up as ordered by the physician. The resident, who was cognitively intact and had gastroesophageal reflux disease, could not eat the meal as served. The deficiency occurred because the dietary change was not communicated to the Dietary Manager, resulting in the Tray Card not being updated.
Unaccounted Narcotics and Misappropriation of Resident Medications via I-STAT Withdrawals
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of property when staff could not account for 19 missing controlled-substance tablets for 10 residents. Facility policies required controlled substances to be stored under double-lock conditions, counted every shift, and any discrepancies reported immediately to the DON. Policies also required that if a medication with an active order could not be located in the cart, staff should search other areas and, if still not found, obtain it from the I-STAT and document administration on the MAR. The abuse and misappropriation policy required investigation of suspected misappropriation and staff education on prevention and reporting responsibilities. The events leading to the deficiency centered on RN A’s repeated withdrawal of narcotics from the I-STAT automated dispensing cabinet without corresponding documentation of administration on the MAR or in the EHR. On one morning, after receiving shift report, RN B observed RN A in the medication room logging into the I-STAT and withdrawing an oxycodone 10 mg tablet under a resident’s name without a request from the CMT assigned to that hall. RN B then saw RN A coming from the bathroom, and RN A made a comment about feeling alive again. The resident under whose name the oxycodone was withdrawn could not recall exactly when they last received a pain pill and only remembered that a female had given it. Review of I-STAT records showed that on multiple prior occasions over several months, RN A had withdrawn oxycodone, hydrocodone-APAP, and tramadol tablets for various residents without any documentation of administration on the MAR. Ten residents with orders for PRN narcotic analgesics were involved. One resident with multiple sclerosis, COPD, atrial fibrillation, dementia, and frequent, constant pain had an order for oxycodone IR 10 mg every four hours PRN; I-STAT records showed several oxycodone tablets withdrawn by RN A on different dates with no corresponding MAR entries. Another resident with brain cancer, COPD, and diabetes had tramadol 50 mg PRN ordered, and a tramadol tablet was withdrawn by RN A without documentation. Additional residents with diagnoses including rhabdomyolysis, hip pain, Parkinson’s disease, Alzheimer’s disease, dementia, heart failure, atrial fibrillation, obesity, unspecified pain, encopresis, cachexia, stroke, and recent amputation had PRN orders for hydrocodone-APAP or tramadol; for each, I-STAT reports showed narcotic tablets removed by RN A on specific dates and times with no documentation of administration in the EHR or MAR. Staff interviews confirmed that narcotics were supposed to be double-locked, counted each shift, signed out on the narcotic log and MAR, and that missing narcotics were considered misappropriation. The consultant pharmacist explained that the I-STAT system tracks cabinet inventory but does not by itself confirm administration, so withdrawals that are not documented on the MAR would not create an automatic discrepancy in the I-STAT count. The DON stated awareness that RN A had a history of medication diversion and had instructed RN A not to administer narcotics, indicating that CMTs were to administer all medications. Despite this, it was later discovered that RN A had been pulling narcotics from the I-STAT. The DON had been running weekly discrepancy reports on the I-STAT and conducting monthly narcotic counts with the consultant pharmacist, but these processes did not detect RN A’s pattern because the I-STAT counts remained correct. Only when the DON ran a report by nurse name and compared each I-STAT withdrawal to the EHR MAR and narcotic log did it become evident that RN A had repeatedly removed narcotics without documented administration, resulting in 19 missing narcotic tablets for 10 residents and constituting misappropriation of resident medications. Interviews with CMTs and an RN confirmed that they performed narcotic counts with off-going staff each shift, maintained double-lock security, did not give their keys to others, and would notify the DON immediately of any discrepancy. They also stated that they signed out narcotics on both the narcotic log and MAR and that they considered missing narcotics to be misappropriation. The consultant pharmacist confirmed that medications were delivered daily and that the pharmacy ran a daily controlled-medication report, but that the I-STAT system alone would not flag missing doses if the cabinet count remained accurate. The Administrator stated that missing narcotics were considered misappropriation of property and that an investigation was initiated after being notified of potential diversion, ultimately revealing that RN A had been removing narcotics from the I-STAT and not administering them to residents. Overall, the facility failed to prevent misappropriation of resident medications by not detecting that RN A, who had a known history of diversion and had been instructed not to administer narcotics, was repeatedly withdrawing controlled substances from the I-STAT without documentation of administration. This resulted in 19 unaccounted-for narcotic tablets intended for 10 residents with documented pain and PRN orders for oxycodone, hydrocodone-APAP, or tramadol, in violation of the facility’s own policies on controlled substances, medication administration, and prevention of misappropriation of resident property.
Misappropriation of Resident Funds via Unauthorized Debit Card Use by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when an environmental services employee used the resident’s debit card without consent for personal financial gain. The resident, who had diagnoses including COPD, chronic respiratory failure, myocardial infarction, and atrial fibrillation, was documented as cognitively intact on a recent MDS, independent in most ADLs, and requesting supervision only with showers. The care plan also noted impaired cognitive or thought processes and impaired visual function requiring use of glasses and supports. Facility policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent and prohibited such conduct. The sequence of events began when the environmental services employee offered to assist the resident with obtaining items and cash from the community. On one occasion, the employee initially brought back food and a receipt with no discrepancies. Subsequently, the employee asked the resident if he needed anything and suggested using the resident’s debit card to withdraw cash from an ATM when the resident did not have cash. The resident provided the employee with the debit card and PIN and requested a $500 withdrawal, but bank records showed an additional unauthorized ATM withdrawal of $103.25 on the same date. On a later date, the employee again took the resident’s debit card to withdraw money; the resident requested $503, but the bank statement showed additional ATM withdrawals of $123.25 and $306.00 that the resident stated were not authorized. Further review of the resident’s bank statements revealed multiple Venmo transactions to the employee over several days totaling $610.00, along with overdraft fees of $150.00, which the resident reported he did not authorize and did not understand, stating he did not know what Venmo was. The resident reported receiving an insufficient funds notice from the bank, which led to discovery of the unauthorized withdrawals and transfers. Law enforcement investigation documented that the employee admitted adding the resident’s card to a Venmo account and acknowledged transactions linked to the resident’s card, and officers photographed the card showing the resident’s name. Interviews with multiple staff, including CNAs, CMT, LPN, SSD, Activity Director, BOM, DON, and the Administrator, confirmed that only designated staff (BOM, Administrator, Activity Director/front office) were permitted to shop for residents, that staff were not allowed to take residents’ debit or credit cards, withdraw money from ATMs, or accept money or gifts from residents, and that using a resident’s debit card for personal use constituted misappropriation of resident funds. Despite these policies and staff knowledge, the environmental services employee obtained the resident’s debit card and PIN, conducted unauthorized ATM withdrawals and electronic transfers, and used the resident’s funds for personal purposes, resulting in misappropriation of the resident’s money.
Failure to Timely Report Suspected Abuse or Neglect
Penalty
Summary
The report identifies a deficiency related to the failure to timely report suspected abuse, neglect, or theft, and to report the results of the investigation to the proper authorities. This deficiency was found during a survey with the Event ID B3N912, which concluded on 11/14/24. The specific details of the incident, including the individuals involved or the nature of the suspected abuse, neglect, or theft, are not provided in the report. However, the deficiency highlights a lapse in the facility's protocol for handling and reporting such critical incidents.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to ensure that food prepared and served to residents was palatable, as evidenced by multiple complaints from residents about the temperature, flavor, and texture of the meals. Observations and interviews revealed that the food was often served cold, lacked seasoning, and was difficult to chew. Specifically, the temperature of the food was found to be below acceptable levels, with the cheesy rice casserole at 110 degrees Fahrenheit, the pork chop at 95 degrees Fahrenheit, and the broccoli at 90 degrees Fahrenheit when served. The Dietary Manager acknowledged that the food was cooler than it should have been to be considered palatable. Residents expressed dissatisfaction with the meals during interviews, noting that the food was cold, overcooked, and lacked flavor. One resident mentioned that the breakfast pancakes were cold, and another reported that the pork chops were tough and hard to chew. Additionally, there were complaints about the inconsistency of the menu, such as being served tortilla chips with meat instead of the expected burrito with beans and rice. These issues indicate a failure in the facility's food preparation and service processes, impacting the residents' dining experience and satisfaction.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of possible neglect involving a resident to the State Survey Agency within the required two-hour timeframe. The incident involved a visitor who accused the facility's Administrator of neglecting a resident by allowing them to lie in bed and die, noting the resident's significant weight loss and unkempt appearance. Despite the visitor's accusations, the Administrator did not consider the comments to be an allegation of neglect and did not report the incident to the Department of Health and Senior Services (DHSS). The facility's policy mandates that any allegations of abuse or neglect must be reported immediately to the Administrator and subsequently to the state agency within two hours. Interviews with facility staff, including a Certified Nurse Aide, the Activity Director, and the Director of Nursing, confirmed their understanding of this requirement. They all indicated that the visitor's comments should have been treated as an allegation of neglect and reported accordingly. The resident in question was admitted with diagnoses including acute kidney failure, severe dementia with agitation, and required substantial assistance with daily activities. The Administrator documented the visitor's accusations but failed to recognize them as a reportable event. This oversight resulted in a failure to comply with the facility's policy and state regulations regarding the timely reporting of potential neglect.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to investigate an allegation of possible neglect involving a resident, as required by their policy and state regulations. A visitor accused the facility's Administrator of allowing a resident to lie in bed and die, citing the resident's significant weight loss and unkempt appearance. Despite this serious allegation, the Administrator did not consider it as potential neglect and did not initiate a full investigation or report the incident to the State Survey Agency within the mandated five-day period. The resident in question was admitted with diagnoses including acute kidney failure, severe dementia with agitation, repeated falls, and required assistance with personal care. The Minimum Data Set indicated the resident was severely cognitively impaired and dependent on staff for various activities of daily living. The visitor's observations of the resident's condition were not documented as part of a formal investigation, and no interviews were conducted with other staff or residents who might have had relevant information. Interviews with facility staff, including a CNA, the Activity Director, and the Director of Nursing, revealed that they would have considered the visitor's statements as allegations of neglect and would have reported them to their supervisors. However, the Administrator, who was responsible for overseeing abuse and neglect investigations, did not perceive the visitor's comments as an allegation of neglect and failed to follow the facility's policy for conducting a thorough investigation and reporting the findings to the appropriate authorities.
Deficiencies in Care Planning for Side Rails and Elopement Risks
Penalty
Summary
The facility failed to develop a complete person-centered care plan for two residents, leading to deficiencies in addressing their specific needs. For one resident, who had a history of frequent falls and unsteadiness, the facility did not include the use of side rails in the care plan, despite the resident's consent and ongoing use of bilateral half side rails for mobility and repositioning assistance. This oversight was confirmed by both the MDS Coordinator and the Director of Nursing, who acknowledged that the use of side rails should have been care planned. Another resident, diagnosed with Alzheimer's disease and identified as at risk for elopement, did not have a care plan addressing their wandering and elopement risk. The resident exhibited daily wandering behavior and had attempted to exit the facility multiple times, requiring redirection from staff. Despite these behaviors being documented in the resident's assessments and progress notes, the care plan did not reflect the necessary interventions. This omission was confirmed by the MDS Coordinator and the Director of Nursing, who expected the wandering behavior to be addressed in the care plan.
Failure to Address Elopement Risks for a Resident with Dementia
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and provide adequate supervision to prevent accidents, specifically for a resident with severe cognitive impairment and a history of wandering. The resident, diagnosed with dementia, had multiple elopement attempts and exhibited combative behavior. Despite these incidents, the facility did not update the resident's care plan with new interventions or conduct a root cause analysis to address the elopement behavior. The resident's care plan identified them as an elopement risk and wanderer, with interventions such as offering pleasant diversions and identifying a pattern of wandering. However, the resident repeatedly exited the facility unsupervised, and staff interventions, including redirection and therapeutic communication, were ineffective. The resident's behavior escalated to hitting staff and attempting to evade them during elopement attempts. Interviews with facility staff, including the Director of Nursing (DON) and Registered Nurses (RNs), revealed that the facility did not complete a root cause analysis for the resident's exit-seeking behavior. The DON confirmed that the resident had not had an elopement assessment since June 2024 until September 2024, and the issue had not been discussed in Quality Assurance meetings. The facility's failure to evaluate the effectiveness of interventions and update the care plan contributed to the ongoing elopement attempts and associated risks.
Failure to Prepare Food According to Resident's Dietary Needs
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of a resident, specifically Resident #17. The resident had a physician's order for a regular texture, regular consistency diet with no gravy and meats to be cut small. However, the resident's Tray Card, which is printed daily by the kitchen, was not updated to reflect these dietary instructions. As a result, during an observation of the lunch tray line, the resident was served a whole pork chop, contrary to the order for the meat to be cut up. The resident, who was cognitively intact and had a diagnosis of gastroesophageal reflux disease, reported being unable to cut the meat and therefore did not eat it. The Director of Nursing (DON) indicated that when a change to a diet is made by the physician, a copy of the change is supposed to be given to the Dietary Manager (DM) for implementation. However, the paperwork for the change in diet for the resident was not communicated to the DM, leading to the deficiency in food preparation for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gainesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care Manor Nursing And Rehab | 16.2 mi | ★★★★★ | 5 | 0 |
| Hiram Shaddox Health And Rehab | 16.9 mi | ★★★★★ | 0 | 0 |
| Lake Forest Senior Living At Mountain Home | 18.2 mi | ★★★★★ | 0 | 0 |
| Gassville Therapy And Living | 20.9 mi | ★★★★★ | 4 | 0 |
| Twin Lakes Therapy And Living | 23 mi | ★★★★★ | 0 | 0 |
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