Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Focused Care Of Gilmer during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence for ADLs, who was receiving Eliquis, slid from bed onto a floor mat and remained on the floor for several hours before being found. Nursing staff manually lifted the resident from the floor back into bed without a mechanical lift or gait belt and did not obtain vital signs, perform neuro checks, or immediately notify the physician, despite an unwitnessed fall and anticoagulant use. Routine rounding every two hours did not occur, and the resident was later sent to the ED at family request. When the resident returned, the receiving LVN did not obtain or secure hospital records, and the facility did not review the ED imaging that documented possible bilateral massive rotator cuff tears and a right humeral head fracture until surveyor intervention. These actions and omissions violated the facility’s own fall and risk management policies and resulted in an Immediate Jeopardy finding for failure to provide care according to professional standards and the care plan.
A resident with advanced dementia, severe functional limitations, and on Eliquis fell from bed onto a floor mat and remained on the floor for over two hours before being discovered by staff. The assigned CNA and RN acknowledged they had not rounded on the resident during that period, despite expectations for 2‑hour checks. When the RN, an LVN, and a CNA returned the resident to bed, they manually lifted him from the floor without a mechanical lift, lift sheet, or gait belt, contrary to facility policy requiring mechanical devices for heavy lifting. The RN did not obtain post‑fall VS or neuro checks, did not notify the physician at the time of the unwitnessed fall, and documentation confirmed these assessments were not completed. Family reported delayed notification and were initially told the resident had not hit his head, while later hospital imaging showed bilateral shoulder abnormalities and a possible fracture. On return from the ED, the receiving LVN did not obtain hospital records, and significant imaging findings were not communicated to or reviewed by facility clinicians at that time, contributing to the cited deficiency under F689.
A facility failed to provide enough towels and washcloths for resident hygiene care, affecting ADLs such as bathing, grooming, and oral care. Multiple residents reported that showers were often missed because towels were not available, and staff said they had to search for linens each day. Observations found several hall linen carts with no towels or only a few towels present, while management and nursing staff confirmed the shortage had continued for months because ordered towels were on back order.
Respiratory care equipment was not maintained as ordered for three residents receiving oxygen therapy. One resident’s concentrator filter was observed covered in dust and dirt, another resident’s oxygen tubing was not changed per the weekly order, and a third resident’s oxygen reservoir water remained dated and unchanged beyond the weekly schedule. Records showed all three residents had diagnoses and assessments supporting oxygen use, and staff interviews confirmed nursing was responsible for cleaning or replacing the equipment as ordered.
Unsecured medications, wound care chemicals, and carts were observed in the facility. A resident with paraplegia had a wound care cleanser left on the bedside table, another resident with respiratory failure had prescription nasal spray, an inhaler, and povidone-iodine left in the room, and a third resident had OTC supplements left unsecured. In addition, a medication cart and a treatment cart were observed unlocked and unattended, with medications visible in the medication cart drawers.
Food items in the kitchen were observed improperly stored and not in accordance with food safety standards. Bread was left on top of a toaster without a date or label, expired green onions were unlabeled and actively decomposing with black liquid in the bag, and margarine was undated with no expiration date listed. The Dietary Manager, DCO, and EDO all stated that food should be labeled, dated, covered, and expired items discarded, and the facility policy required safe storage to prevent contamination and food-borne illness.
Failure to Accommodate Resident Needs and Access to Furnishings and Call Light: A resident with paraplegia and dependence for ADLs could not reach her nightstand because staff did not turn her bed as requested, leaving snacks and belongings stored in her bed. Another resident with vascular dementia and substantial/maximal ADL assistance had her call light on the floor and out of reach while she reported nausea and needed medication. Staff interviews confirmed call lights should be kept within reach and that residents’ needs should be accommodated.
A resident with severe cognitive impairment and painful bilateral lower-leg wounds had Hydrocodone-Acetaminophen missing from the narcotic supply. The MAR showed PRN pain medication orders, the pharmacy record showed 55 tablets delivered, and staff later could not locate one narcotic card and its count sheet. Interviews indicated nurses were responsible for shift-change narcotic counts and securing the meds, but the missing controlled substance was not accounted for during the facility’s review.
Failure to Care Plan Oxygen Therapy: A resident with respiratory failure, pulmonary edema, and severely impaired cognition required oxygen therapy and had an order for O2 at 2 L NC to keep SpO2 above 90%, but the care plan did not include oxygen therapy. The DON and Administrator stated oxygen use should be documented on the care plan, yet it was absent from the resident’s plan of care.
Pressure Redistribution Mattresses Not Set Correctly: Two residents with skin concerns, including one with an unstageable sacral PI and another with a knee wound, were observed in bed with pressure redistribution mattress settings at 430 pounds despite lower documented weights. Staff, including an RN, LVN, DCO, and EDO, stated the beds should be set to the residents' weights and that nurses were responsible for ensuring the settings were correct; the facility policy required mattress settings to follow manufacturer guidelines.
Missing Catheter Securement Device: A resident with an indwelling Foley catheter, urinary retention, and severe cognitive impairment was observed without a catheter securement device in place during incontinent care. CNA, RN, and leadership interviews confirmed the resident should have had the device, and the facility policy called for a catheter strap to secure the tubing.
Infection Control Lapses With PPE Use and Feeding Tube Handling: A resident on EBP was observed receiving incontinent and catheter care while a CNA left the room wearing the gown to get gloves and then returned to continue care in the same gown. Another resident with a gastrostomy tube was repeatedly observed with the feeding tubing port uncapped and either open to air or on the floor. Staff stated PPE should be removed before leaving the room and feeding tubing should be capped and kept off the floor.
A resident with CHF, gout, muscle weakness, gait impairment, and a history of falls did not have a call light button attached to the call light system and did not have a call light available at the bedside. The resident, who had intact cognition and needed supervision with all ADLs, was observed without an accessible call light on multiple occasions, and staff interviews confirmed the call light was missing and should have been accessible to the resident.
A resident with paraplegia and a history of bowel issues missed a scheduled surgical consultation because the facility failed to provide transportation, despite being aware of the appointment in advance. The regular van driver called in sick, and no backup driver was available in time. Attempts to arrange alternative transportation were unsuccessful, resulting in the cancellation of the appointment.
A resident with significant mobility and toileting needs was found in an unclean room with strong urine odors, sticky floors, and flies present. Staff interviews revealed urinals were not emptied as frequently as required, leading the resident to empty them into a trashcan, causing spills and persistent odors. Housekeeping staff cleaned daily but lacked specialized products to address urine smells, and leadership acknowledged the ongoing issue and the need for more frequent checks.
Two residents with indwelling catheters and a history of incontinence did not receive proper infection control during catheter and incontinent care, as CNAs failed to change gloves and perform hand hygiene when moving between dirty and clean tasks, and handled clean items after contact with soiled materials, despite documented training and care plans addressing their needs.
Two CNAs provided incontinent care to a resident with a Foley catheter, gastrostomy tube, and wound without wearing required PPE, despite having completed EBP training and PPE being available. The resident was medically complex and dependent on staff for care. Staff interviews revealed inconsistent understanding and application of EBP protocols, and facility policy required PPE use for such care activities.
A medication aide failed to administer physician-ordered medications to three residents due to unavailability during a medication pass. The residents, with conditions such as quadriplegia, dementia, and depression, did not receive their prescribed Pepcid and paroxetine (Paxil). The aide did not report the shortage to management, highlighting a communication breakdown in maintaining medication supplies.
A medication aide in an LTC facility failed to administer medications as ordered, resulting in a 15.22% error rate. Errors included not administering Pepcid and Paxil due to unavailability and incorrect dosing of Vitamin C. The aide mixed medications contrary to training, affecting four residents with various conditions such as quadriplegia, dementia, and leukemia.
The facility failed to ensure proper labeling and disposal of expired foods in the kitchen, as observed during a survey. Unlabeled and expired items were found in the refrigerator and dry storage, and staff interviews revealed inconsistencies in checking and discarding expired foods. The Dietary Manager and Administrator acknowledged the lapses, which could risk foodborne illness to residents.
The facility failed to maintain safe and sanitary conditions in the personal refrigerators of three residents, leading to the presence of expired and improperly stored food items. A resident's refrigerator was found dirty with unlabeled food, another contained expired soup, and a third had expired fruits. Housekeeping staff were responsible for checking refrigerators but did not consistently check for expired foods, despite facility policy requiring proper food storage and disposal. This deficiency could potentially place residents at risk for foodborne illness.
The facility failed to maintain an effective infection prevention and control program, as evidenced by lapses in hand hygiene and equipment sanitation. Two CNAs did not change gloves or sanitize hands during incontinent care, and a medication aide failed to sanitize hands and clean a blood pressure cuff between residents. These actions were against the facility's infection control protocols, potentially putting residents at risk of infection.
A resident with atherosclerotic heart disease, requiring extensive assistance with activities of daily living, was found with long, jagged fingernails and a thick black substance under them, indicating a lack of proper nail care. Staff interviews revealed confusion over responsibilities, with a CNA assuming hospice or the treatment nurse handled nail care. The treatment nurse confirmed weekly checks but had not done so until late on the day of observation. The DON and Administrator acknowledged the lack of a specific policy on nail care.
A resident in a facility experienced delays in care due to insufficient staffing, with only one nurse often on duty, particularly overnight. Staff reported being sent home early, leaving inadequate coverage for resident needs. Despite concerns raised by staff, the administration maintained current staffing levels, citing corporate directives, even though the facility's assessment indicated a need for more staff.
Two residents' bathrooms were found without call light pull cords, posing a risk in case of falls. Both residents, one with hemiplegia and the other with COPD, were at risk for falls and required assistance with toileting. Staff interviews revealed a lack of awareness and communication regarding the missing cords, with the Maintenance Director unaware of the issue due to no work orders being submitted.
The facility failed to provide mandatory QAPI training to two CNAs, hired in 2017 and 2024, respectively. The ADON, responsible for training oversight, was unaware of the deficiency, using a manual system to track training. The Administrator, also unaware, acknowledged the potential impact on resident care due to untrained staff.
Two residents in a long-term care facility experienced verbal and physical abuse by a CNA during incontinent care. Despite being trained on abuse policies, the CNA was rough and spoke inappropriately to the residents, causing emotional distress. The facility confirmed the abuse through an investigation and terminated the CNA after a week of employment.
Failure to Assess, Monitor, and Follow Up After Anticoagulated Resident’s Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards, the resident’s care plan, and the resident’s clinical status following a fall. An elderly male resident with dementia, severe cognitive impairment, functional limitations in all extremities, and total dependence for ADLs was on Eliquis, an anticoagulant. His care plan identified a history of falls and required post-fall monitoring for 72 hours, including neurological checks and observation for changes in mental status, pain, bruising, and other signs of injury. On the evening in question, video evidence showed the resident slowly sliding from his bed onto a floor mat, ultimately lying on his left side with his head and face on the mat. The resident remained on the floor for approximately two to three hours before being discovered by staff. A housekeeper found him on the floor next to the bed, and RN A and LVN B responded. Video recordings showed that RN A, LVN B, and a CNA manually lifted the resident from the floor mat back into bed by holding under his arms and legs, without using a mechanical lift or gait belt. Interviews with RN A, LVN B, and the CNA confirmed that no vital signs or neurological checks were performed at the time of the fall, despite the fall being unwitnessed and the resident being on a blood thinner. RN A acknowledged he did not obtain vital signs or neuro checks, did not contact the physician after the fall or when the resident was sent to the hospital, and did not check on the resident prior to the fall during that shift. The CNA reported she had not rounded on the resident between the start of her shift and the time he was found on the floor, and that routine rounding every two hours did not occur. The facility also failed to obtain, review, and follow up on the resident’s hospital records after he was sent to the emergency department at the family’s request the following morning. Progress notes documented that the resident returned from the ED without any paperwork from the hospital. LVN E, who received the resident back from the hospital, stated that no records accompanied him, that she was told by the hospital that records had been given to the family, and that she requested a fax but did not receive it. The DON and Administrator stated that the receiving nurse was responsible for ensuring hospital records were obtained and for following up if they were not. Hospital documentation, later obtained during the survey, showed imaging findings of elevation of both humeral heads suggesting massive rotator cuff tears and a possible fracture of the right humeral head. The facility’s nurse practitioner reported she was only notified of these significant diagnostic findings during the survey and had not been able to order timely follow-up because the hospital records had not been obtained or reviewed by facility staff. Family interviews corroborated that the resident lay on the floor for an extended period, that they were notified late at night, and that they were told he had not hit his head, despite the hospital HPI describing a fall in which he struck his head on the floor. Family members also reported bruising on the resident’s head and shoulder and a scratch on his back, and expressed concern that vital signs and neurological checks were not done and that the transfer from the floor back to bed was improper. The DON and Director of Rehabilitation, after viewing the video, stated that the transfer technique used by staff was inappropriate and that a mechanical lift or gait belt should have been used. The facility’s own fall and risk management policy required a head-to-toe assessment, vital signs, pain assessment, environmental assessment, physician and responsible party notification, and neurological checks for any unwitnessed fall or fall involving the head, which were not carried out in this case. These combined failures led to the identification of an Immediate Jeopardy related to quality of care for this resident.
Failure to Supervise, Assess, and Safely Transfer a Resident After an Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident’s environment as free of accident hazards as possible and to provide adequate supervision and post‑fall assessment. An elderly male resident with dementia, severe cognitive impairment, functional limitations in all four extremities, and total dependence for bed mobility and transfers was care planned as at risk for falls, with interventions including fall mats, anticipating needs, prompt assistance, and staff assistance for all mobility. He was on Eliquis, an anticoagulant. Video provided by family showed the resident in bed with his head, shoulder, and arm off the side of the bed, reaching toward the bedside dresser, then gradually sliding off the bed and onto the floor mat, coming to rest on his left side with his head and face on the mat. The time stamp on this video was approximately 8:05 p.m. A second video, time stamped around 10:25 p.m., showed the resident still lying on the floor mat on his side next to the bed when an LVN and an RN entered the room. The LVN stated they would need a mechanical lift, and the RN briefly left the room. A third video, beginning around 10:28 p.m., showed the RN, LVN, and a CNA manually moving the resident from lying on the mat to a seated position and then lifting him back into bed by placing their hands under his arms and legs and lifting him together, without use of a mechanical lift, lift sheet, or gait belt. This manual lift occurred despite a facility policy stating that manual lifting of residents shall be eliminated when feasible and that mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. The Director of Rehabilitation later characterized the transfer as inappropriate, and the DON stated she did not think the transfer was proper and believed a mechanical lift or lift sheet should have been used. Progress notes documented that the resident was found on the floor next to his bed by a housekeeper, with fall mats in place, and that no injuries were initially noted. Interviews with the CNA assigned to the hall and the RN revealed that neither had checked on the resident between the start of the shift and the time he was found on the floor; the CNA stated she usually rounded every two hours but had not checked on him before he was found, and the RN stated he first saw the resident only when notified he was on the floor. The CNA acknowledged that if she had checked on him earlier, she might have found him sooner. The RN admitted he did not obtain vital signs or perform neurological checks after the unwitnessed fall, despite recognizing that such assessments are important, especially for unwitnessed falls, and acknowledged he did not contact the physician at the time of the fall or when the resident was sent to the hospital. The LVN who assisted with the transfer stated she did not see the RN obtain vital signs, perform an assessment, or complete neurological checks while she was in the room and believed the resident should have been sent out at the time of the fall. Family members reported they were not notified of the fall until several hours after it occurred and were initially told the resident did not hit his head. They later described observing bruising on his head and shoulder and a scratch on his back. Hospital records from the subsequent ED visit documented that the resident had fallen from bed, primarily onto his left side, with video reviewed at the hospital indicating he had been on the floor for about two hours, and that he was on Eliquis. Imaging of both shoulders showed elevation of both humeral heads suggesting massive rotator cuff tears and possible fracture of the right humeral head. The facility’s own documentation showed that neurological checks and vital signs were not completed after the fall, and the DON confirmed that post‑fall vital signs and neurological checks were not done. The facility also failed to ensure that hospital records, including the abnormal imaging findings, were obtained and reviewed when the resident returned from the hospital; the receiving LVN reported that no paperwork accompanied the resident, that she requested records and a fax but did not receive them, and that she was told by hospital staff that everything was clear. The nurse practitioner later stated she was only notified of the imaging findings on a later date and would have ordered follow‑up imaging and an orthopedic consult had she been informed when the resident returned. The CNA and RN both acknowledged staffing limitations on the night of the fall, including the absence of a medication aide and only two CNAs on duty, and the RN stated he was busy passing medications and did not check on the resident prior to the fall. The CNA confirmed that she was assigned to the resident’s hall, usually rounded every two hours, but did not check on the resident until around the time he was found on the floor. The DON and Administrator both stated they expected nurses and CNAs to check on residents every two hours and that vital signs and neurological checks should be completed after a fall, particularly for a resident on a blood thinner. The combination of delayed discovery of the resident on the floor, failure to monitor him at least every two hours, failure to perform timely and complete post‑fall assessments (including vital signs, neurological checks, and physician notification), failure to use appropriate lifting equipment or techniques to return him to bed, and failure to obtain and review hospital records with significant diagnostic findings constituted the deficient practice that led to the Immediate Jeopardy determination.
Lack of Towels Prevented ADL Hygiene Care
Penalty
Summary
The facility failed to provide care and services in accordance with residents’ activities of daily living for hygiene-bathing, dressing, grooming, and oral care for 13 of 13 residents reviewed for ADLs. During confidential interviews, all 13 residents stated the facility often did not have towels available and that CNAs were not giving showers because washcloths and bath towels were not supplied by the facility. The residents also stated they had complained about the issue, but it had not improved. Observations of the linen carts on multiple halls showed that towels were not consistently available. On Hall 200, Hall 300, and Hall 400 linen carts, no towels were present during some observations. Later observations showed only one bath towel on Hall 100, one face towel and two bath towels on Hall 200, two face towels and three bath towels on Hall 300, and no towels on Hall 400. A record review of the facility invoice showed washcloth and towel orders had been placed in November 2025, but the towels were on back order. The facility in-service binder did not contain in-services related to the lack of towels for residents’ hygiene needs. Staff interviews confirmed the shortage and its effect on resident care. A CNA and a laundry aide stated towels were hard to find every day and staff had to hunt for them in the facility. The laundry aide and multiple nursing and management staff said residents were not getting showers or morning face and hand washing because the facility did not have enough towels and washcloths. The Director of Environmental Services and the Director of Plant Operations stated towels had been ordered monthly since November and were still on back order, and several staff identified housekeeping, laundry, environmental services, or plant operations as responsible for ensuring towels were available.
Respiratory Care Equipment Not Maintained as Ordered
Penalty
Summary
The facility failed to ensure that residents who required respiratory care received it as ordered for three residents. The report states that Resident #14, Resident #35, and Resident #2 all had oxygen therapy orders and were identified in records as needing respiratory support, but staff did not consistently maintain the oxygen equipment according to the physician orders and facility policy. For Resident #14, the record showed diagnoses including COPD, sepsis, and UTI, and the quarterly MDS indicated she was cognitively intact with a BIMS score of 15 and required oxygen therapy. Her care plan addressed ineffective breathing pattern related to COPD, and the physician ordered oxygen at 2 liters per nasal cannula and cleaning or changing the oxygen concentrator filters every Sunday night shift. During observation, the resident said she did not know when staff cleaned her oxygen concentrator, and the concentrator filter was observed covered in dust and dirt on two separate occasions. For Resident #35, the record showed diagnoses including acute and chronic respiratory failure with hypercapnia, acute pulmonary edema, and cognitive communication deficit. Her MDS showed a BIMS score of 03 and indicated she required oxygen therapy. The physician ordered oxygen at 2 liters per nasal cannula and oxygen tubing changes every Sunday night shift, but the care plan did not document oxygen therapy or oxygen usage. During observations, the resident was using oxygen through nasal cannula and the label on the oxygen concentrator read 2/16/26 on multiple occasions. The Director of Clinical Operations and the Executive Director of Operations stated that nursing staff were responsible for changing oxygen tubing and cleaning or replacing filters as ordered. For Resident #2, the record showed diagnoses including acute on chronic systolic congestive heart failure, COPD, diabetes, and morbid obesity. Her MDS indicated severe cognitive impairment with a BIMS score of 7, shortness of breath while lying flat, and a need for oxygen. Her care plan included oxygen therapy related to COPD, and the MAR showed weekly oxygen tubing changes with documentation that the tubing was last changed on 2/15/26. During observation, the resident was on 3 liters of oxygen and the oxygen concentrator water was dated 2/5/26 and had not been changed out. Staff interviews stated that nurses were responsible for changing the water and tubing, that the water should be changed weekly, and that the dated water observed would be overdue.
Unsecured medications, chemicals, and carts
Penalty
Summary
Drugs and biologicals were not stored in locked compartments for several residents and two carts were left unsecured during observation. The facility also failed to securely store wound care chemicals for one resident, prescription respiratory medications and povidone-iodine solution for another resident, and over-the-counter supplements for a third resident. The report states that these items were found in resident rooms or on carts where they were accessible rather than being kept in locked storage. For one resident with paraplegia, muscle wasting and atrophy, and depression, the quarterly MDS showed a BIMS score of 10 and dependence for activities of daily living. During observation, a bottle of wound care cleanser was left on the bedside table. The resident said she did not know what was in the green spray bottle and believed someone had left it in her room. An LVN stated that chemical products should be in the treatment cart or medication cart and that such chemicals should not be left in resident rooms. For another resident with respiratory failure with hypoxia, venous insufficiency, and acute pulmonary edema, the quarterly MDS showed a BIMS score of 13 and dependence for most activities of daily living. During observation, two bottles of fluticasone propionate nasal spray, fluticasone propionate and salmeterol powder, and povidone-iodine 10% solution were observed in the resident’s room. The resident said staff had left the medications with her. The report also states that a medication cart and a treatment cart were observed unlocked and unattended, with staff away from the carts for several minutes, and that OTC medications and resident medications were visible in the medication cart drawers.
Food Items Left Undated, Unlabeled, and Expired in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during a kitchen observation. On 2/22/26 at 10:01 a.m., bread was observed sitting on top of a toaster without being dated or labeled. Bags of green onion were observed expired, dated 1/17/2026, and unlabeled, and the onions were decomposing inside the bag and releasing black liquid. Blocks of margarine were also observed undated and labeled with no expiration date listed on the packaging. During interviews, the Dietary Manager stated that food should be labeled and dated, covered properly, and that expired or actively decomposing food in the refrigerator should have been thrown away. She stated that all kitchen staff were responsible for ensuring regulations were followed. The Director of Clinical Operations stated that kitchen staff were expected to follow regulations to prevent foodborne illness, and the Executive Director of Operations stated that food in the kitchen should be stored properly, labeled, dated, and expired food thrown away. Record review of the facility's Food Storage policy dated 2/2026 stated that food should be stored in a safe and sanitary method to prevent contamination and food-borne illness, and that bulk items and opened items should be stored in covered containers or sealed bags, labeled and dated.
Failure to Accommodate Resident Needs and Access to Furnishings and Call Light
Penalty
Summary
The facility failed to reasonably accommodate resident needs and preferences for Resident #17, Resident #52, and Resident #69. The deficiency specifically involved Resident #17 being unable to access her bedroom furnishings and Resident #69 being unable to access her call light. The report states these issues were identified during observation, interview, and record review, and that the failure could place residents at risk for unmet needs and decreased quality of life. Resident #17 was a female with diagnoses including paraplegia, muscle wasting and atrophy, and needs for assistance with personal care. Her record showed a BIMS of 09 and that she was dependent for ADLs. During observation, she said she stored snacks in her bed because staff would not turn her bed so she could reach her nightstand, which was positioned at the foot of the bed. Multiple jars of protein powder, peanut butter, and other snack items were observed in her bed, and she said she used a Hoyer lift to get out of bed. She reported asking staff multiple times to change the direction of her bed so she could use her nightstand, but nothing happened. Resident #69 was a female with diagnoses including vascular dementia, type II diabetes, morbid obesity, and bipolar disorder. Her MDS reflected a BIMS of 11 and substantial/maximal assistance with ADLs, and her care plan included ensuring her call light was in reach and answered promptly. During observation, she told the surveyor she was sick to her stomach and needed medication for nausea, but her call light was on the floor and out of reach, leaving her unable to reach staff. Staff interviews confirmed that call lights should be within reach and that staff were responsible for ensuring residents could access them.
Missing Controlled Medication
Penalty
Summary
The facility failed to ensure a resident was free from misappropriation of property when Hydrocodone-Acetaminophen prescribed for pain was missing from the medication supply. The resident was a male readmitted to the facility with diagnoses including chronic venous hypertension with bilateral lower-extremity ulcers, sepsis, diabetes mellitus, and lymphedema. His quarterly MDS indicated severe cognitive impairment with a BIMS score of 6, and he required assistance with toileting, bathing, personal hygiene, and lower-body dressing. His care plan identified pain potential and included interventions for pain assessment and medication administration as ordered. The resident’s MAR showed Hydrocodone-Acetaminophen 7.5-325 mg ordered every 4 hours as needed for pain. The pharmacy narcotic sheet documented delivery of 55 tablets, and the resident received doses on two occasions in early February. A pain assessment later documented pain at 2 out of 10 related to bilateral lower-leg wounds, and the resident refused pain medication at that time. The facility later identified that the narcotic supply was missing, including one card with 8 tablets remaining and another card with 30 tablets that was missing along with its narcotic count sheet. The facility initiated an investigation into the missing medication and reviewed staff handling of the narcotics. Interviews showed staff were responsible for counting narcotics at shift change and securing them in the locked medication cart, but the missing narcotic card and count sheet could not be located. The DCO stated the missing medication was identified during a medication review, the police were notified the next day, and staff who handled the medication cart were interviewed and drug tested. The facility policy required immediate investigation of discrepancies, loss, or diversion of medication, notification of leadership and the consultant pharmacist, and review of controlled drug accountability procedures when a controlled substance was involved.
Failure to Care Plan Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #35 that included the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Record review showed Resident #35 was a [AGE]-year-old female admitted on [DATE] with diagnoses including Acute and Chronic Respiratory Failure with Hypercapnia, Acute Pulmonary Edema, and Cognitive Communication Deficit. Her quarterly MDS dated 1/27/26 reflected a BIMS score of 03, indicating severely impaired cognition. Resident #35 required oxygen therapy on admission and while a resident, and an order dated 10/21/25 directed oxygen at 2 liters per nasal cannula to maintain oxygen saturation greater than 90%. However, the care plan dated 1/23/26 did not include any information about oxygen therapy. During interview, the DON stated oxygen therapy should be on a resident’s care plan and that she was responsible for ensuring care plans were accurate and documented all resident care. The Administrator also stated that if a resident received oxygen therapy, it should be documented on the care plan.
Pressure Redistribution Mattresses Not Set to Correct Weight Settings
Penalty
Summary
The facility failed to ensure pressure redistribution mattresses were set to the correct weight settings for two residents with skin integrity concerns. Resident #16 had diagnoses including cellulitis of the buttocks, morbid obesity, and an unstageable sacral pressure ulcer, and was dependent with ADLs. Resident #64 had diagnoses including local skin and subcutaneous tissue infections, morbid obesity, and abnormal posture, was dependent with ADLs, and had current skin concerns including a right proximal knee wound. Record review showed both residents had orders allowing use of a pressure redistribution mattress and both were identified as at risk for pressure ulcers or injuries. Resident #16 weighed 409 pounds on the face sheet, with subsequent weights documented at 344.6 pounds, 340.0 pounds, and 367.0 pounds. Resident #64 weighed 334 pounds. During observations on multiple days, both residents were lying in bed and each resident's pressure redistribution mattress weight setting was observed at 430 pounds. During interview, RN D stated she expected the residents' beds to be set appropriately to their weights and said the nurses were responsible for ensuring the beds were set to the resident's weight. LVN A stated she knew both residents had weight loss and had complained about feeling like they were laying on the bars of the bed frame and asked for the mattress to be increased. The Director of Clinical Operations and the Executive Director of Operations both stated they expected the residents' redistribution beds to be set to the correct setting and that nurses were responsible for ensuring the settings were correct. The facility's Skin Management policy stated mattress settings would be used according to manufacturer's guidelines.
Missing Catheter Securement Device
Penalty
Summary
The facility failed to ensure Resident #18, a female with neuromuscular dysfunction of the bladder, urinary retention, and need for assistance with personal care, had a catheter securement device in place for her indwelling Foley catheter. Her record showed she was usually understood and understood others, had a BIMS score of 4 indicating severely impaired cognition, required maximal assistance with ADLs, was occasionally incontinent of bowel, and had a catheter for urinary continence. Her care plan identified the indwelling Foley catheter and noted she was at risk for increased urinary tract infection, with an intervention to check tubing for kinks each shift. The order summary also directed staff to check Foley placement and ensure the Foley was secured via a securing device to reduce friction and pulling every shift. During an observation, CNA B provided incontinent care to Resident #18 and the resident had a Foley catheter without a securement device in place. In interview, CNA B stated the resident should always have a catheter securement device and said the nurse was responsible for putting it on. RN D stated the resident was supposed to have a securement device in place and that nurses were responsible for ensuring it was present. The Director of Clinical Operations and the Executive Director of Operations also stated the resident should have had a securement device in place, and the facility policy on indwelling catheter care stated to attach a catheter strap to the leg to assist in securing tubing.
Infection Control Lapses With PPE Use and Feeding Tube Handling
Penalty
Summary
The facility failed to maintain infection prevention and control practices for two residents. Resident #18 had diagnoses including neuromuscular dysfunction of the bladder, urinary retention, and need for assistance with personal care. Her MDS reflected severe cognitive impairment, maximal assistance with ADLs, occasional bowel incontinence, and a catheter for urinary continence. Her care plan and orders indicated she was on enhanced barrier precautions for an indwelling catheter, with gown and gloves to be used for high-contact care activities. During an observation on 2/23/26 at 1:56 P.M., CNA B performed incontinent care on Resident #18 and left the resident’s room while still wearing the gown to get gloves. During a later observation at 2:03 P.M., CNA B returned and performed catheter care while wearing the same gown she had worn in the hallway. During interview, CNA B stated she knew she should have taken the gown off when she left the resident’s room to get gloves and identified the negative effect as cross contamination. RN D stated she expected CNAs to remove PPE when leaving a resident’s room on EBP and said staff were responsible for following the protocol by removing PPE before leaving the room. Resident #36 had diagnoses including severe protein-calorie malnutrition, resistance to multiple antimycobacterial drugs, dysphagia, gastrostomy status, and acute metabolic acidosis. His care plan and orders reflected tube feeding via gastrostomy. On multiple observations, his feeding tubing port was found uncapped and either open to air or on the floor while he was lying in bed. LVN E stated nurses were responsible for maintaining residents’ feeding tubes and expected the tubing to be secured and off the floor. The Director of Clinical Operations and the Executive Director of Operations both stated nurses were responsible for preventing contamination of the feeding tubes and expected the tubing to be capped and not on the floor.
Missing Resident Call Light
Penalty
Summary
The facility failed to ensure that Resident #52 had a working call light button attached to the call light system and available from the bedside. Resident #52 was a [AGE]-year-old male who had been admitted and readmitted to the facility, with diagnoses including chronic systolic congestive heart failure, chronic gout due to renal impairment, muscle wasting and atrophy, difficulty walking, muscle weakness, other abnormalities of gait and mobility, unspecified lack of coordination, and a history of falling. His MDS assessment dated 12/16/25 reflected that he was understood and understood by others, and his BIMS score was 13, indicating intact cognition. Resident #52 required supervision assistance with all ADLs and was always incontinent of bowel and bladder. His care plan identified him as at risk for increased falls and fractures due to impaired mobility and included interventions to anticipate needs, provide prompt assistance, encourage him to ask for staff assistance, and ensure the call light was in reach and answered promptly. During observations on 2/22/26, 2/23/26, and 2/24/26, Resident #52 did not have a call light button attached to the call light system when he was not in the room. During an interview on 2/22/26, Resident #52 stated he did not have a call light and had only noticed a call light for his bed, which he did not use because he did not need assistance often. Staff interviews on 2/24/26 and 2/25/26 confirmed that the resident did not have a call light and that staff expected call lights to be accessible to residents. The Director of Plant Operations, Director of Clinical Operations, Executive Director of Operations, RN, CNA, and LVN all stated that residents should have accessible call lights and that staff across the building shared responsibility for ensuring they were available.
Failure to Provide Transportation for Medical Appointment
Penalty
Summary
The facility failed to provide transportation for a resident to a scheduled medical appointment, despite being aware of the appointment two weeks in advance. The resident, who had paraplegia and required dependent assistance with all activities of daily living, was scheduled for a consultation with a colon surgeon regarding a colostomy due to a swollen colon. Documentation showed that the appointment was known to staff, and reminders were given by a family friend on the day of the appointment. However, the facility did not arrange for transportation, citing the absence of the regular van driver, who called in sick that morning, and the unavailability of a backup driver in time for the appointment. Interviews with staff and family members confirmed that the facility had only one designated driver at the time, and the backup driver was not available early enough to transport the resident. The maintenance staff member, who also served as the van driver, notified the facility early in the morning that he would not be able to work. Attempts to secure alternative transportation, including contacting local emergency medical and transportation services, were unsuccessful. As a result, the appointment was canceled to avoid a fee for a missed appointment, and the resident did not receive the scheduled medical evaluation. The facility's policies indicated that they were responsible for assisting residents in arranging transportation to medical appointments. Despite this, the lack of a backup driver and the failure to secure alternative transportation led to the resident missing an important medical consultation. The incident was corroborated by interviews with the resident, family members, and facility staff, all of whom acknowledged the missed appointment and the facility's inability to provide transportation as required.
Failure to Maintain Clean, Odor-Free, and Homelike Resident Environment
Penalty
Summary
A deficiency was identified when a resident's room was found to be unclean and had a persistent strong urine odor. The resident, a male with hypertensive heart disease, paraplegia, and spinal stenosis, required total assistance with toileting hygiene and was occasionally incontinent of urine. Observations revealed that the resident kept two urinals hanging on a trashcan beside his bed, both containing urine, and the floor near the bed and trashcan was wet, sticky, and had flies present. The resident reported that staff did not empty his urinals frequently enough, leading him to sometimes empty them into the trashcan himself, which contributed to the odor and uncleanliness in the room. Interviews with staff confirmed that urinals should be emptied at least every two hours, but this was not consistently done. A CNA noted that the urinal was overflowing and urine had spilled onto the floor, which she attempted to clean. Housekeeping staff reported ongoing issues with urine odor in the room, attributed to the resident's use of urinals and occasional incontinence, and stated that while the room was cleaned daily, there were no special cleaners available to address urine odors. The housekeeping supervisor and other staff acknowledged the persistent odor and the challenges in maintaining cleanliness, despite daily cleaning and attempts at deep cleaning. Facility leadership, including the Assistant Director of Clinical Operations and the Administrator, recognized that staff should have been checking and emptying the urinals more frequently. They also noted that the resident did not like staff entering his room at night, which may have contributed to the issue. The facility's policy emphasized the importance of a clean, sanitary, and homelike environment, but the ongoing presence of urine odor and unclean conditions in the resident's room demonstrated a failure to meet these standards.
Failure to Follow Infection Control Practices During Incontinent and Catheter Care
Penalty
Summary
The facility failed to ensure that two residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTIs) and to restore continence to the extent possible. For one resident with a history of frontotemporal neurocognitive disorder, Down syndrome, paraplegia, and neuromuscular dysfunction of the bladder, a CNA did not follow proper infection control practices during catheter and incontinent care. The CNA did not clean or place a barrier on the bedside table before placing supplies, failed to change gloves and perform hand hygiene when moving from dirty to clean tasks, and handled clean items after touching soiled materials without changing gloves. The CNA acknowledged these lapses during an interview, stating he should have changed gloves and performed hand hygiene at multiple points during care. For another resident with multiple sclerosis, neurogenic bladder, and a history of recurrent UTIs, a different CNA also failed to follow infection control protocols during incontinent care. The CNA washed her hands and donned gloves initially but did not perform hand hygiene when changing gloves between dirty and clean tasks. She also handled clean linens without changing gloves after providing care to soiled areas. The CNA admitted she should have used hand sanitizer and changed gloves at appropriate times but did not have sanitizer available and became distracted during care. Both residents had care plans and physician orders addressing their incontinence, catheter use, and risk for UTIs, including specific medications and interventions. Despite documented competency evaluations for the CNAs, direct observation revealed that infection control practices were not consistently followed during care. Facility leadership confirmed their expectations for proper hand hygiene and glove use during such care, and acknowledged the importance of these practices in preventing infection.
Failure to Ensure Staff Use PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff consistently followed infection prevention and control protocols, specifically Enhanced Barrier Precautions (EBP), when providing care to a resident with multiple risk factors for infection. On the date in question, two CNAs provided incontinent care to a resident who had a Foley catheter, gastrostomy tube, and a wound, without wearing the required personal protective equipment (PPE). This was confirmed through photo evidence submitted by a responsible party, which showed the staff members not wearing PPE during the care activity. Both CNAs had completed EBP training prior to the incident, and facility records indicated that PPE was available and that signage and supplies were in place to support compliance with EBP protocols. The resident involved was an older male with significant medical complexity, including end stage renal disease, osteomyelitis, heart failure, neuromuscular bladder dysfunction, a gastrostomy, peripheral vascular disease, and a below-the-knee amputation. He was dependent on staff for most activities of daily living, including toileting and mobility, and was unable to complete a BIMS assessment. The care plan and physician orders specified that the resident was to be on EBP due to his Foley catheter, gastrostomy tube, and chronic wounds, with interventions including staff and family education, signage, and ready access to PPE. Interviews with staff revealed inconsistent understanding and application of EBP protocols. One CNA could not recall if PPE was worn during the incident and admitted to not always using PPE, while the other CNA demonstrated a lack of understanding regarding when gowns were required. Other staff, including the ADON, DON, and additional CNAs, acknowledged the importance of EBP and the availability of PPE, but also noted ongoing challenges with staff compliance despite repeated in-servicing. Facility policy required PPE use for high-contact care activities for residents on EBP, but the observed failure to follow these protocols led to the identified deficiency.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents, as observed during a medication pass. The medication aide, MA E, did not administer Pepcid to three residents as ordered by their physicians. Additionally, one resident did not receive their prescribed paroxetine (Paxil). These medications were not available during the medication pass, despite being ordered by the physicians. Resident #1, a male with quadriplegia, osteoarthritis, and dysphagia, did not receive his Pepcid medication as ordered. Resident #41, a male with hemiplegia, dementia, and type 2 diabetes mellitus, also did not receive his Pepcid medication. Resident #206, a female with dementia, depression, and gastroesophageal reflux, did not receive her Pepcid or paroxetine (Paxil) medications. The failure to administer these medications as ordered could potentially impact the residents' health and quality of life. The medication aide, MA E, acknowledged not administering the medications due to a lack of available stock and did not report the shortage to the Director of Nursing (DON) or Assistant Director of Nursing (ADON). The facility's policy requires maintaining a seven-day supply of medications, but there was a breakdown in communication between the medication aide and management, leading to the unavailability of the medications. The DON, ADON, and Administrator were unaware of the medication shortages and emphasized the importance of communication to ensure medications are available as needed.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 15.22% due to 7 errors out of 46 opportunities. These errors involved four residents and one medication aide (MA E) and one LVN. The errors included the failure to administer medications as ordered by the physician, such as Pepcid and Paxil, due to unavailability, and incorrect dosing of Vitamin C. Resident #1, a male with quadriplegia, osteoarthritis, and dysphagia, did not receive his prescribed Pepcid due to the medication not being available. Similarly, Resident #41, with hemiplegia, dementia, and type 2 diabetes, also did not receive his Pepcid for the same reason. Resident #206, a female with dementia, depression, and gastro-esophageal reflux, did not receive her prescribed Pepcid or Paxil because the medications were not available. Resident #17, a male with lymphocytic leukemia, depression, and atrial fibrillation, received an incorrect dose of Vitamin C and had his medications mixed together, contrary to training instructions. The medication aide, MA E, confirmed these errors and admitted to not reporting the unavailability of medications to the charge nurse. The Assistant Director of Nurses and the Director of Nursing were unaware of the medication shortages and emphasized the importance of following the five rights of medication administration.
Failure to Properly Label and Discard Expired Foods
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, the facility did not ensure that food stored in the kitchen refrigerator and dry storage area was properly labeled, dated, and free from expiration. During an observation, it was noted that the refrigerator contained a bag of black olives and a tray of lettuce that were not labeled or dated. Additionally, the dry storage area contained cracker crumbs, flour tortillas, and coffee packages that were past their expiration dates. Interviews with staff revealed inconsistencies in the process of checking and discarding expired foods. A staff member mentioned that the kitchen staff were supposed to check expiration dates upon delivery and regularly inspect all products, but this process was not consistently followed. The Dietary Manager (DM), who had been at the facility for about two weeks, acknowledged the responsibility of checking expiration dates and was in the process of orienting staff on proper food storage procedures. The Administrator expected daily and weekly checks for expired foods, emphasizing the DM's responsibility in ensuring compliance. The facility's policy required all food to be labeled with receive and open dates and discarded before expiration, but these procedures were not consistently implemented, posing a risk of foodborne illness to residents.
Failure to Maintain Safe and Sanitary Conditions in Resident Refrigerators
Penalty
Summary
The facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors, which led to unsafe and unsanitary conditions in the personal refrigerators of three residents. Resident #21's refrigerator was observed to be dirty, with an orange sticky substance spilled at the bottom, and contained unlabeled and undated food items, including leftover desserts from the kitchen. Resident #42's refrigerator contained expired broccoli cheddar soup, and Resident #23's refrigerator had expired peaches and pears. These conditions were identified during observations and interviews with the residents, who indicated that they or their family members sometimes cleaned the refrigerators, but staff assistance was also involved. The facility's housekeeping staff were responsible for checking the residents' personal refrigerators daily for temperature and cleanliness, but they did not check for expired foods. The Maintenance Director, who supervised housekeeping, stated that staff were trained to check for expired foods, but this was not being done consistently. The Director of Nursing (DON) acknowledged that personal refrigerators needed to be cleaned weekly, with expired foods discarded, but this had not been consistently implemented. The Administrator and Assistant Director of Nursing (ADON) also recognized the responsibility of housekeeping to maintain the cleanliness and safety of personal refrigerators. The facility's policy titled "Food from Outside Sources" required community personnel to manage appropriate temperatures and food storage in resident refrigerators, with cold items discarded based on labeled dates or three days after opening. However, the policy was not effectively enforced, as evidenced by the presence of expired and improperly stored food items in the residents' refrigerators. This lack of adherence to policy and procedure could potentially place residents at risk for foodborne illness.
Infection Control Lapses in Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several lapses in hand hygiene and equipment sanitation. During an observation, two CNAs did not change gloves or perform hand hygiene while providing incontinent care to a resident. They moved from handling soiled items to clean items without sanitizing their hands, which is against infection control protocols. Both CNAs acknowledged their failure to follow proper procedures, attributing it to nervousness. Additionally, a medication aide did not sanitize her hands during medication administration for multiple residents. She handled medication bottles and equipment without performing hand hygiene before, between, or after resident interactions. Furthermore, she used a blood pressure cuff on two residents without cleaning it between uses. The aide admitted to being aware of the proper procedures but failed to follow them due to nervousness. Interviews with the ADON and DON confirmed that staff are trained on infection control protocols, including hand hygiene and equipment sanitation, during hire and annually. However, the observed failures indicate a lapse in adherence to these protocols, potentially putting residents at risk of infection. The facility's policies on hand hygiene and equipment cleaning were not followed, as evidenced by the staff's actions during the survey.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living, specifically in maintaining personal hygiene, including nail care. The resident, an elderly female with a diagnosis of atherosclerotic heart disease, required extensive assistance with most activities of daily living and had moderately impaired cognitive skills. Observations revealed that the resident's fingernails were long, jagged, and had a thick black substance under them, indicating a lack of proper nail care. Interviews with staff revealed a lack of clarity and responsibility regarding nail care. A CNA, who had been assigned to the resident, admitted to not noticing or cleaning the resident's fingernails, assuming that hospice staff or the treatment nurse had done so. The treatment nurse confirmed that she checked nails weekly but had not done so until late in the afternoon on the day of observation. The Director of Nursing and the Administrator acknowledged that aides were responsible for daily nail checks and cleaning, while the treatment nurse was responsible for weekly checks and trimming. However, there was no specific policy on nail care or activities of daily living care in place at the facility.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff with the appropriate competencies and skills to meet the needs of residents, specifically impacting a resident who experienced delays in having her call light answered and receiving basic care such as ice and water. The resident, who had diagnoses including hemiplegia, epilepsy, and cognitive communication deficit, reported that the facility was often short-staffed, leading to extended wait times for care. Interviews with staff confirmed that CNAs were sent home early to cut down on hours, leaving insufficient staff to adequately care for all residents. Interviews with various staff members, including CNAs and LVNs, revealed that the facility often operated with only one nurse on duty, particularly during overnight shifts. This staffing level was deemed insufficient by the staff, who expressed concerns about their ability to perform necessary care and interventions in emergency situations. Despite these concerns being communicated to the facility's administration, the staffing levels remained unchanged due to directives from corporate management. The Director of Nursing (DON) and the Administrator both acknowledged the staffing issues but believed the current staffing was adequate, citing the lack of daytime activity during night shifts. However, the facility's own assessment indicated a need for more staff than was being provided. The Administrator admitted to following a corporate template for staffing assessments without fully understanding the requirements, leading to discrepancies between the facility's staffing plan and actual staffing levels. This misalignment posed risks to resident safety and care quality.
Missing Call Light Cords in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the bathrooms of two residents, identified as Resident #107 and Resident #110, were equipped with a functioning call light pull cord. This deficiency was observed on two separate occasions, where it was noted that the call light pull cords were missing from the bathrooms of these residents. Resident #107, a male with a history of hemiplegia and hemiparesis following a stroke, was at high risk for falls and required moderate assistance with toileting. Resident #110, a female with chronic obstructive pulmonary disease, was also at risk for falls and was dependent on assistance for toileting. Both residents had intact cognition and were continent of bowel and bladder. Interviews with the residents revealed that they were unaware of the missing call light cords and expressed concern about their ability to call for help in the event of a fall. A CNA with several years of experience at the facility acknowledged the absence of the cords and indicated that call lights should be checked during rounds. The Maintenance Director, responsible for ensuring the functionality of call lights, was unaware of the missing cords and stated that no work orders had been submitted for their replacement. The Administrator confirmed that the Maintenance Director was responsible for call light maintenance and emphasized the importance of daily checks by staff to ensure all call lights were operational.
Failure to Provide Mandatory QAPI Training to CNAs
Penalty
Summary
The facility failed to ensure that mandatory Quality Assurance and Performance Improvement (QAPI) training was provided to two Certified Nursing Assistants (CNAs), identified as CNA G and CNA L, as part of its QAPI program. CNA G, hired on July 13, 2017, had not completed the required annual QAPI training, and CNA L, hired on February 6, 2024, had not completed any QAPI training. During interviews, the Assistant Director of Nursing (ADON) acknowledged her responsibility for overseeing training and admitted to being unaware of the incomplete QAPI training for these CNAs. The ADON used a manual binder system to track training, which may have contributed to the oversight. The facility's Administrator, who is ultimately responsible for training oversight, also stated she was unaware of the training deficiencies but recognized the potential impact on resident care if staff were not properly trained.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The facility failed to protect two residents from verbal and physical abuse by a certified nursing assistant (CNA) identified as CNA G. Resident #1, a female with a history of cognitive impairment, fractures, and other medical conditions, reported that CNA G was rough during incontinent care, causing emotional distress. Multiple interviews confirmed that CNA G spoke rudely to Resident #1 and handled her roughly, although no physical injuries were reported. The investigation revealed that CNA G's behavior was confirmed as abusive, leading to her suspension and eventual termination. Resident #2, who had mild dementia and required assistance with activities of daily living, also reported rough treatment by CNA G during care. Interviews with staff and the resident indicated that CNA G was rough and spoke inappropriately during care. Although Resident #2 did not suffer physical harm, the incident was distressing, and the resident expressed relief at CNA G's termination. The facility's investigation confirmed the abuse, and CNA G was terminated after only a week of employment. The facility's records showed that CNA G had been trained on abuse policies and resident rights upon hiring. Despite this training, her conduct during care was found to be abusive towards the residents. The facility's administration and nursing staff were involved in the investigation, and the abuse was reported to the necessary authorities. The facility took immediate action by suspending and then terminating CNA G, but the incidents highlighted a failure to protect residents from abuse during her brief tenure.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Gilmer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gilmer Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 27 | 0 |
| Legend Oaks Healthcare And Rehabilitation Center - | 12.2 mi | ★★★★★ | 14 | 0 |
| Truman W Smith Children's Care Center | 12.9 mi | ★★★★★ | 5 | 0 |
| Pine Tree Lodge Nursing Center | 16.1 mi | ★★★★★ | 19 | 2 |
| Avir At Pittsburg | 18 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.