Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Gilmer Nursing And Rehabilitation during CMS and state inspections, most recent first.
Dignity and Mealtime Assistance Concerns: A CNA stood over two residents while helping them eat and used her personal cell phone while assisting one resident with feeding and while sitting with another resident. The residents had severe cognitive impairment and needed assistance or supervision with eating. Interviews with the LVN, CNA, DON, and Administrator confirmed staff should sit at the residents’ level, explain care, and remain off cell phones during mealtime assistance.
Incomplete Care Plans for Anticoagulant and Eye Drop Therapy: The facility failed to include prescribed Eliquis therapy in the care plans for two residents and failed to include prescribed eye drops for another resident. The MDS nurse acknowledged the omissions, and the DON verified the missing care plans. The residents had diagnoses including AFib, dementia, and eye conditions, and the facility policy required comprehensive, person-centered care plans with measurable objectives and timeframes.
Menu Not Followed for Fish Taco Lunch Service: A lunch meal was served with one crispy fish taco instead of the two listed on the menu for multiple residents in both the secure unit and main dining room. An LPN stated she did not notice the meal tickets called for two tacos and did not check the trays, while the cook admitted she knowingly served only one taco because residents did not like the meal. The Dietician, DON, and Administrator all stated the menu and correct portion sizes were expected to be followed.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors observed undated cream cheese, a dirty pureed mixer top, wet dome covers/bowls/trays stacked with water pooled between them, and personal items including a cell phone, drink mug, and work bag in the food prep area. An aide and the DM were also observed with hairnets that did not fully cover their heads, with loose hair sticking out. Interviews confirmed staff responsibility for dating food, keeping hair fully covered, air-drying dishware before stacking, and storing personal items away from the work area.
Missing Current Hospice Records for Residents on Hospice The facility failed to keep current hospice documentation available for residents receiving hospice services. For one resident, the hospice binder lacked the most current plan of care, IDG reports, medication report, physician orders, and hospice visit notes; for another, the most current IDG notes were missing; and for a third, the current hospice certification of terminal illness and plan of care were not present. Interviews showed staff and hospice representatives were unclear about who was responsible for keeping the hospice binders current, despite residents having significant cognitive impairment and terminal diagnoses.
A resident with HTN and moderately impaired cognition had her full name and BP information texted from an LPN’s personal cell phone to the MD when asking about holding antihypertensive meds. The LPN, DON, and MD stated texting via personal phones was acceptable, and the Administrator noted initials or room number would have been ideal; the facility had no system for monitoring secure information release, and the Resident Rights policy did not address confidentiality of personal and medical information.
Verbal abuse during medication dispute: A resident with dementia, major depressive disorder, and other chronic conditions returned from oral surgery with pain medication and rinse instructions. During an overnight conflict about ibuprofen and other post-op meds, an LPN argued with the resident and told her, "that's why you are in a nursing home." The resident said the comment made her feel belittled, and the LPN acknowledged the remark and that she should have called the doctor for clarification.
Failure to Timely Report Abuse Allegation: A resident with dementia, major depressive disorder, heart disease, and HTN alleged that an LVN argued with her overnight about post-op medication orders and told her, "that's why you are in a nursing home," leaving her feeling belittled. The facility policy required abuse allegations to be reported to HHSC within 2 hours, but the report was submitted after that timeframe.
Late Admission MDS Assessment: A resident with severe dementia, HTN, and CKD stage 3 did not have the admission MDS completed within the required timeframe. The MDS was still in progress after the ARD, and the MDS Coordinator said it was delayed while gathering information. The DON said she was not familiar with the required timeframe and did not notice the later MDS signature date when she signed it.
PASRR Level 1 screening was not completed on admission for one resident with dementia and bipolar disorder, and another resident’s PASRR was inaccurate because PTSD was not marked as a mental illness even though it was an active diagnosis. The MDS Nurse acknowledged the missed and incorrect PASRR entries, and the Administrator stated PASRRs were expected to be entered on admission and accurately reflect active diagnoses so residents could receive needed services.
A resident admitted with renal failure had physician orders for dialysis three times weekly, but the baseline care plan did not include dialysis instructions. The MDS Nurse and DON verified the omission, and the Administrator stated the baseline care plan was expected to include the resident’s dialysis needs.
An LPN failed to administer an inhaler as ordered for a resident with COPD, giving 1 puff instead of 2 puffs before later returning for the second puff. The same LPN also administered a resident’s Novolog FlexPen without priming the pen per manufacturer instructions before giving the ordered 1-unit dose. The DON and pharmacist consultant confirmed the expected dosing and priming process, and the facility’s policies required medications to be given as prescribed and in accordance with physician orders.
Failure to Clarify Post-Op Pain Orders: A resident returned from oral surgery with swelling and postoperative instructions that included hydrocodone-acetaminophen, amoxicillin, ibuprofen, and salt water rinses. An LVN knew the resident was requesting ibuprofen but did not administer it because there was no EMR order and did not contact the prescriber for clarification, despite the resident’s repeated requests and the DON and Administrator stating the instructions should have been clarified.
Fall Mat Not in Place for a Resident at Risk for Falls. A resident with dementia, bipolar disorder, and severely impaired cognition required extensive staff assistance and had a care plan and order for fall mats at bedside while in bed. After a recent fall from bed to the mat, surveyors observed one mat on the floor and the other standing against the bed while the resident was lying in bed. An LVN, DON, and Administrator stated staff were responsible for keeping the mats in place.
Missed Eye Drops and Improper Insulin Pen Preparation: A resident with eye disease did not receive ordered ophthalmic drops, and the MAR showed the dose was omitted without a documented reason. In a separate event, an LVN administered Novolog FlexPen insulin to a resident with DM without priming the pen first, despite the manufacturer’s instructions and the facility’s stated expectation that the pen be primed before use.
Medication administration errors exceeded the allowed rate when surveyors observed two errors during med pass. An LPN gave a resident with COPD only 1 puff of an ordered albuterol inhaler instead of 2 puffs, and gave another resident’s Novolog insulin without priming the pen first. The DON and pharmacist consultant confirmed the ordered inhaler dose and the insulin pen priming process, and the facility’s policies required meds to be given as prescribed and in accordance with physician orders.
Failure to Honor a Resident's Food Dislike: A resident with Alzheimer's disease and severe cognitive impairment was served corn even though her meal ticket listed corn as a dislike and she stated she could not have it due to diverticulitis. Interviews showed the cook, nurses, Dietary Mgr, DON, and Administrator expected tray cards and dislikes to be checked and honored, but staff did not review the tray card before the meal was served.
Missed Ordered Health Shake: A resident with malnutrition, dementia, and dysphagia was ordered a pureed diet with a house supplement at meals, but a health shake was not on her lunch tray. During observation, CNA staff and the Dietary Manager confirmed the supplement was missing, and the Dietary Aide said she overlooked the tray card. The DON and Administrator stated dietary and nursing staff were responsible for ensuring ordered supplements were served.
Failure to follow EBP during wound care: A resident with MASD to both buttocks and an order for enhanced barrier precautions received wound care from the Wound Care Nurse without a gown. The nurse stated she forgot because the order was new, and the DON and Facility Administrator stated they expected staff to follow EBP orders to prevent spread of infection.
Failure to Follow Designated Smoking Area Policy: A dietary aide was observed smoking on the sidewalk near the kitchen back door instead of in the designated smoking area. She said she sometimes smoked in her truck or in rocking chairs in front of the facility and believed she could smoke anywhere outside. The Administrator and HR Coordinator stated staff and residents were expected to use the same designated outdoor smoking area, and the facility policy required employees, residents, medical staff, and visitors to smoke only in that area.
A resident with early-onset Alzheimer’s disease, severe cognitive impairment, and dependence on staff for bathing did not have her shower preferences documented in her care plan and was scheduled for nighttime showers based on a standardized hall-based bathing schedule. Her family repeatedly requested that showers be provided during the day, but staff, including the DON and ADON, stated they would only provide day-shift showers when time allowed and otherwise continued with night-shift bathing. As a result, the resident frequently received late-night bed baths instead of showers, and her hair was observed to be greasy, limp, and clumped together, indicating that her expressed preference for daytime showers was not honored.
A resident with severe cognitive impairment and dependence on staff for bathing had repeated missed showers and went over two weeks without having her hair washed because showers were scheduled on the night shift, when she was already in bed and instead received bed baths. The resident’s family member repeatedly asked the ADON and DON to move the shower time to days to match the resident’s sleep schedule, but these requests were not documented in the grievance log, and the care plan did not reflect the resident’s shower preferences. The DON acknowledged knowing about the requests but did not treat them as grievances due to the standard hall-based bathing schedule, and the ADON admitted she was unsure of the grievance process and did not record the complaints, contrary to the facility’s grievance policy requiring prompt resolution of grievances.
Surveyors found a treatment cart left unlocked and unattended on a resident hall, with a wound cleanser bottle on top and prescription triamcinolone cream accessible in the top drawer. Staff and residents were present nearby, and no staff intervened when the cart was opened by a surveyor. The Treatment Nurse later reported she had stepped away to assist an aide and had not locked the cart or stored the wound cleanser, despite facility policy requiring medications and potentially harmful substances to be securely stored and accessible only to authorized personnel. The Administrator and DON both stated their expectation that treatment carts remain locked or under direct supervision at all times.
A resident with dementia, recurrent UTIs, and prophylactic antibiotic therapy developed increased agitation, confusion, and exit-seeking behaviors, prompting an order for UA with C&S. The UA was sent to the physician, but when the C&S later returned abnormal and positive for E. coli, the result was not entered on the 24-hour report or promptly communicated to the physician on the day it was received. Nursing leadership and corporate compliance staff reported that nurses were responsible for checking labs each shift and using the 24-hour report and clinical meetings to ensure follow-up, but this process was not followed, resulting in delayed physician notification of the abnormal lab result.
A resident with multiple chronic conditions, moderate cognitive impairment, and dependence on staff for toileting received incontinent care from two CNAs who removed a soiled brief but did not change their soiled gloves or perform hand hygiene before applying barrier cream. Both CNAs later stated they knew they were required to remove soiled gloves and perform hand hygiene during peri care but failed to do so. The DON and Administrator confirmed that staff are expected to follow facility policy requiring glove changes and hand hygiene during perineal care to prevent infections, and records showed both CNAs had previously been deemed competent in perineal/incontinent care.
The facility did not have an RN on duty for 8 consecutive hours on a holiday, as required. The DON was not present, and no other RN was assigned. The Administrator acknowledged the oversight and the absence of a policy for RN coverage.
A facility failed to coordinate PASRR assessments by not including a hospice representative in IDT meetings for a resident needing specialized PT and OT services. This oversight led to the denial of PT services and potential delays in OT services due to incomplete information submitted to the PASRR Unit. The resident, with a history of seizures and intellectual disabilities, was affected by this deficiency.
The facility failed to develop comprehensive care plans for three residents with PASRR positive status, risking missed services. A resident with schizoaffective disorder, another with cerebral palsy and diabetes, and a third with anxiety had care plans that did not address their PASRR status. Interviews revealed the MDS nurse was responsible for this oversight, which was acknowledged by facility staff.
A facility failed to inform a resident's family about changes in Medicare coverage by not providing a SNF ABN when skilled services were discontinued. The resident, who had dementia and other health issues, continued on Medicaid services without the family being notified of the change. Staff interviews revealed a lack of awareness and training regarding the responsibility for issuing SNF ABN letters.
A facility failed to include a resident's depression diagnosis and prescribed antidepressant medication in the baseline care plan upon admission. The resident, an elderly male, was admitted with a diagnosis of depression and a physician's order for Amitriptyline. Interviews with the DON and Administrator highlighted that the care plan should have been informed by the resident's transfer papers, and its absence could lead to inadequate monitoring of the resident's condition.
A facility failed to remove expired medications from a medication cart, affecting a resident with dementia and anxiety. The resident's ABH gel syringes had expired, but due to a misunderstanding of expiration dates on labels, they were not removed. Nurses were responsible for removing expired medications, but confusion arose from labeling practices. Despite the oversight, the expired medication was not administered, though it could have been less effective.
The facility failed to maintain the gas stove in the kitchen in safe operating condition. One of the burners did not light using the pilot light and could not be lit with a lighter. The maintenance supervisor acknowledged the need for cleaning the pilot light and later confirmed that it was cleaned. The Administrator noted the absence of a specific equipment maintenance policy but expected the stove to function properly.
A resident with severe cognitive impairment fell and was improperly transferred back to bed by CNAs without a nurse's assessment, leading to a delayed diagnosis of a femur fracture. The resident later required increased pain management and adjustments to her care plan. The facility's staff failed to follow proper procedures, resulting in a breakdown of communication and protocol adherence.
Dignity and Mealtime Assistance Concerns
Penalty
Summary
The facility failed to treat residents with respect and dignity during mealtime assistance for 3 of 3 residents reviewed for resident rights. Resident #9, an older male with Alzheimer’s disease, hemiplegia and hemiparesis after a cerebral infarction, and a BIMS score of 0, required one staff member to assist with eating. During observation, CNA K stood next to him while feeding him pudding, pressed the spoon against his lips before he opened his mouth, and then pulled out her personal cell phone and looked at it while continuing the feeding assistance. Resident #12, an older female with Alzheimer’s disease and dementia, also had a BIMS score of 0 and a care plan noting a communication problem and the need to anticipate and meet her needs. During observation, she was seated at a table in the secure unit dining area with CNA K, who was using her cell phone while sitting with the resident. Resident #31, an older male with chronic systolic congestive heart failure and dementia, had a BIMS score of 4 and required partial/moderate assistance with eating and supervision as needed. During observation, CNA K was standing over him while assisting him with his lunch. Interviews confirmed that staff expected CNAs to sit at the residents’ level, explain what they were doing, and remain off their cell phones while providing meal assistance. LVN L stated standing over residents was demeaning and that CNA K should not have been on her phone. CNA K acknowledged she should have sat next to the residents, explained her actions, and stepped away to use her phone instead of using it in front of Resident #12. The DON and Administrator also stated staff should sit at the residents’ level, provide face-to-face care, and not have cell phones in patient care areas while assisting residents with meals.
Incomplete Care Plans for Anticoagulant and Eye Drop Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents with identified needs related to prescribed medications and treatments. Resident #52, a female with diagnoses including atrial fibrillation, stroke, diabetes, and high blood pressure, had an order for Eliquis 5 mg twice daily, but her care plan last reviewed on 01/07/26 did not reflect an anticoagulant care plan. Resident #1, a male with diagnoses including pneumonia, dementia, dysphagia, and high blood pressure, also had an order for Eliquis 5 mg twice daily, but his care plan dated 02/13/26 did not reflect an anticoagulant care plan. Resident #39, a male with diagnoses including detachment of the retina of the left eye and macula of the left eye, had an order for Refresh Tears Ophthalmic Solution 0.5% to be instilled in both eyes twice daily for dry eyes. His quarterly MDS assessment reflected that he was cognitively intact, but the assessment did not show eye medication use during the look-back period, and his care plan last reviewed on 12/12/25 did not reflect a care plan for dry eyes. The facility's MDS Nurse stated she was responsible for resident care plans and acknowledged that Eliquis for the two residents and eye drops for Resident #39 should have been added to their care plans when the MDS assessments were completed. The DON verified that Resident #52 and Resident #1 did not have care plans for Eliquis and that Resident #39 did not have a care plan for his eye drops. The DON stated the IDT was responsible for ensuring care plans were started and updated during weekly meetings. The Administrator stated the MDS Nurse was responsible for care plans. The facility policy required a comprehensive person-centered care plan for each resident, developed within 7 days after completion of the comprehensive assessment and reviewed after admission, quarterly, annual, and significant change MDS assessments.
Menu Not Followed for Fish Taco Lunch Service
Penalty
Summary
Menus were not followed for the lunch meal when seven residents in the secure unit dining room and seven residents in the main dining room were served one crispy fish taco instead of the two fish tacos listed on the extended week four menu. During the lunch meal observation, LVN C stated she did not notice the meal tickets indicated the residents should have received two fish tacos and did not check the trays because she believed the trays had already been checked by LVN A and the Treatment Nurse in the main dining room. In the main dining room, the residents also received one fish taco instead of two. During interviews, [NAME] B stated she was responsible for ensuring correct portion sizes were served and acknowledged she knew the correct serving size, but gave only one fish taco because the residents did not like the meal and could ask for more if they wanted it. The Dietician stated she expected [NAME] B to follow the menu and that cooks should review the tray card to ensure it matched the menu and correct portion size, while nurses should check the tray at the door before serving residents. LVN A, the Treatment Nurse, the Dietary Manager, the DON, and the Administrator all stated the menu should have been followed and trays should have been checked for the correct portion size before service.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
Food service safety deficiencies were identified in the kitchen during observation and interview. Four boxes of 3 lb. cream cheese were observed in the refrigerator without dates. The pureed mixer top had a green thick substance on it. Dome covers, bowls, and trays were stacked while still wet with water pooled between them. A cell phone and personal drink mug were on the tray rack where food could be stored, and a work bag was observed under the serving table. During the kitchen observation, Dietary Aide D and the Dietary Manager were observed with hairnets that did not fully cover their heads, with loose hair sticking out. In interviews, Dietary Aide D stated all staff were responsible for dating food products, that hair nets should always cover the entire head without loose hair sticking out, and that personal items such as her cell phone, work bag, and drink mug should have been stored away from the work area. Dietary Aide E stated she had been trained to let dishes air dry before stacking them and said the wet stacking occurred because she was rushing to wash all the dishes. The Dietary Manager stated she was responsible for making sure the kitchen was cleaned appropriately and that all food should be dated by the date received. She also stated hair nets should cover the entire head without loose hair sticking out, the pureed mixer top should be free from food debris, dome covers, bowls, and trays should be air dried before stacking, and personal items should not be in the work area. The Administrator stated she expected food to be dated, hair nets to fully cover the head, personal items to be stored away from the workstation, dome covers, bowls, and trays to be air dried before stacking, and the pureed mixer top to be cleaned before being placed back on the mixer.
Missing Current Hospice Documentation for Residents Receiving Hospice Services
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate LTC staff participation in the hospice care planning process for residents receiving hospice services. Surveyors found that the current hospice documentation was not present in the clinical record for three residents reviewed for hospice services, including missing or outdated hospice plans of care, interdisciplinary group reports, medication reports, physician orders, and hospice visit notes. For one resident, the hospice binder contained only records dated from late January through mid-February 2026, and the current hospice plan of care, interdisciplinary group reports, medication report, physician orders, nurse visit notes, aide visit notes, chaplain visit notes, and social worker visit notes were not in the current clinical record. The resident was a 90-year-old female with diagnoses including Alzheimer's disease, generalized anxiety disorder, and memory deficit following cerebrovascular disease, and she was receiving hospice services while residing at the facility. During interviews, hospice and facility staff stated that the hospice binders were supposed to be kept updated, but the hospice representative responsible for bringing updated information had been on extended leave and the facility had no one currently designated to ensure the binders were current. For another resident, the hospice binder contained an interdisciplinary group meeting note, but the most current interdisciplinary group notes were not obtained. For a third resident, the hospice binder contained an expired hospice certification of terminal illness and an older hospice plan of care, but there was no current certification of terminal illness and no current hospice plan of care. This resident had diagnoses including Alzheimer's disease and dementia and was receiving hospice services. Interviews with hospice and facility staff showed that the hospice records were expected to be available in the facility, but staff were unclear about who was responsible for ensuring the documents were current and available for coordination of care.
Confidentiality Breach in Resident Medication Communication
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of Resident #5’s personal medical information when the Treatment Nurse used her personal cell phone to text the Medical Director about the resident’s blood pressure and medication administration. Resident #5 was a female admitted with essential hypertension, and her quarterly MDS reflected a BIMS score of 11, indicating moderately impaired cognition. Her care plan included giving antihypertensive medications as ordered, and her physician orders included Amlodipine Besylate 5 mg daily and Losartan Potassium 50 mg daily, both with hold parameters for low blood pressure or low heart rate. A text message from the Treatment Nurse to the Medical Director included Resident #5’s full name and reported her blood pressure as 177/59, asking whether it was okay to still give the blood pressure medications. During interview, the Treatment Nurse stated she had called the physician first, then texted because he did not answer, and acknowledged she should have used the room number instead of the resident’s full name. The Medical Director stated it was acceptable to text the resident’s full name using a personal cell phone, and the DON stated staff normally notified physicians by text or phone using personal cell phones. The Administrator stated the ideal would be to text initials or room number and that Resident #5’s personal medical records could be comprised; the facility also had no system in place for monitoring and overseeing the release of secured information. The facility policy titled Resident Rights did not address confidentiality of personal and medical information.
Verbal abuse during medication dispute
Penalty
Summary
The facility failed to ensure Resident #42 was free from verbal abuse when LVN F told her, "that's why you are in a nursing home" during a conflict over post-operative pain medication after oral surgery. Resident #42 was a female resident with diagnoses including dementia, major depressive disorder, heart disease, and high blood pressure. Her quarterly MDS indicated she was cognitively intact with a BIMS score of 15, could make herself understood and understand others, and required extensive staff assistance with toileting, transfers, bed mobility, and showers. Resident #42 returned to the facility after oral surgery with instructions for pain management that included hydrocodone-acetaminophen, amoxicillin, ibuprofen, and warm salt water rinses. She reported that LVN F argued with her all night about the medication orders and refused to listen when she explained the oral surgeon’s instructions for ibuprofen and Tylenol to help with pain and swelling. Resident #42 said LVN F’s comment made her feel belittled, and she stated that her mouth had swollen because the instructions were not followed. During interviews, the Dietary Manager said she overheard LVN F and Resident #42 arguing over pain medications in the early morning hours, with Resident #42 saying she would call her doctor and LVN F responding that she had to call the facility doctor for new orders. LVN F acknowledged she did not administer ibuprofen because there was no order in the electronic medical record, said she should have called the doctor for clarification, and admitted she made the comment about being in a nursing home, though she claimed it was said to herself. The DON and Administrator both stated they understood the comment could be viewed as abuse from the resident’s point of view and that it left Resident #42 upset and at risk of anxiety.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit abuse and neglect and failed to follow its reporting policy when a resident alleged abuse by an LVN. Resident #42, a cognitively intact female with diagnoses including dementia, major depressive disorder, heart disease, and high blood pressure, was admitted with a care plan noting occasional verbal outbursts and argumentative behavior with staff. After oral surgery, she reported that LVN F argued with her all night about the medication orders from the oral surgeon and refused to listen when she said she was supposed to receive ibuprofen and Tylenol for pain and swelling. Resident #42 also stated that when LVN F was leaving her room, the LVN told her, "that's why you are in a nursing home," which made her feel belittled. The facility policy required allegations of abuse to be reported to HHSC within 2 hours, but the reported incident was entered into Tulip 2 hours and 33 minutes after it was reported to the Administrator by the surveyor. During interview, the Administrator acknowledged she knew the allegation was abuse when it was reported to her and stated she was trying to ensure the staff member would not be working at the facility until the investigation was completed.
Late Admission MDS Assessment
Penalty
Summary
The facility failed to complete Resident #19’s comprehensive admission MDS assessment within 14 calendar days after admission. Resident #19 was a female admitted with diagnoses including severe dementia with other behavioral disturbance, hypertension, and chronic kidney disease stage 3. Record review showed the admission MDS assessment with an assessment reference date of 03/03/2026 was still in progress on 03/10/2026 and 03/11/2026, and it was not completed until 03/12/2026. The MDS assessment indicated an entry date of 02/18/2026, and the MDS Completion Date in Section Z0500B was signed completed on 03/04/2026, while the MDS Coordinator signed Sections I8000H, I8000I, and I8000J on 03/12/2026. During interview, the MDS Coordinator stated she completed the admission MDS late because she was gathering information and acknowledged it should have been completed within the required timeframe. She also stated the assessment should have been completed by 03/03/2026. The DON said she believed the admission assessment should be completed within 5 days of admission, was not familiar with the required timeframes, and did not notice that the MDS Coordinator’s signature date was 03/12/2026 when she signed the assessment. The Administrator stated she expected MDS assessments to be completed within the required timeframes, and the Regional Compliance Nurse stated the facility followed the RAI manual. The RAI manual cited in the record states the MDS Completion Date for an admission assessment must be no later than 13 days after the Entry Date.
PASRR Level 1 Screening Not Completed or Accurately Documented
Penalty
Summary
The facility failed to ensure the PASRR Level 1 screening for one resident was completed and submitted upon admission. Record review showed the resident was admitted with diagnoses including dementia, bipolar disorder, and high blood pressure, and the quarterly MDS indicated a BIMS score of 4 with severely impaired cognition. The PASRR Level 1 screening for this resident was completed only after surveyor intervention, and the MDS Nurse stated she had missed completing it and that it should have been done upon admission. The facility also failed to ensure the PASRR Level 1 screening for another resident accurately reflected the resident’s mental health status. Record review showed this resident was admitted with PTSD, COPD, depression, and high blood pressure. The quarterly MDS indicated a BIMS score of 10, moderate cognitive impairment, and active mood disorder, PTSD, and depression. However, the PASRR Level 1 screening marked the resident negative for mental illness, intellectual disability, and developmental disability, despite the PTSD diagnosis being present on admission and later documented in the comprehensive care plan. During interview, the MDS Nurse stated she should have listed PTSD as a yes on the PASRR for mental illness and said she would have to do another PASRR and notify the local authority. The Administrator stated she expected PASRRs to be input on admission and entered correctly for active diagnoses so residents could get the services they needed. The facility policy stated a PL1 screening form should be obtained on day of admission or prior to admission and entered timely according to PASRR regulatory timeframes.
Baseline Care Plan Missing Dialysis Instructions
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #63 that included the instructions needed to provide effective and person-centered care within 48 hours of admission. Resident #63 was a male admitted with a diagnosis of renal failure/kidney failure, and his physician orders dated 03/08/26 included dialysis on Tuesday, Thursday, and Saturday with a chair time of 11:45 a.m. However, the resident’s care plan dated 03/09/26 did not indicate that he had a baseline care plan addressing dialysis. During interviews, Resident #63 stated that he went to dialysis on Tuesday, Thursday, and Saturday and that he had gone the day before one of the interviews. The LVN who completed the baseline care plan could not be reached for interview. The MDS Nurse verified that Resident #63 did not have a baseline care plan for dialysis and stated that care plans reflect the care the resident should receive and that missing interventions could be missed. The DON also verified the absence of dialysis on the baseline care plan and stated that if the care plan was not done, nurses might not know the resident’s needs. The Administrator stated that the baseline care plans were expected to include Resident #63’s dialysis.
Medication Administration Errors With Inhaler and Insulin Pen
Penalty
Summary
The facility failed to ensure medication services were provided in accordance with the comprehensive care plan and professional standards of quality for two residents. Resident #47 had COPD/emphysema and an active order for Albuterol HFA Sulfate Inhalation Aerosol Solution, 2 puffs inhaled every six hours. During an observation, LVN A handed the resident the inhaler and instructed her to inhale 1 puff, then gave her water and left the room. When asked, LVN A stated the resident should have received 2 puffs and returned to the room to have the resident take a second puff. LVN A stated she usually did not walk the resident through the inhaler steps and said she failed to instruct the resident to inhale 2 puffs while the surveyor was present. Resident #7 had Type 2 diabetes mellitus and an active order for Novolog FlexPen, 1 unit subcutaneously before meals and at bedtime. During observation, LVN A prepared the insulin pen, attached the needle, and turned the dose knob to 1 unit, then administered the medication to the resident’s LLQ. LVN A did not prime the insulin pen by turning the dose knob to 2 units before resetting it to 1 unit. LVN A stated she had never primed the insulin pen before administering the resident’s insulin and acknowledged that insulin should be administered according to the manufacturer’s instructions to ensure the correct dosage. The pharmacist consultant stated the insulin pen should be primed with 2 units for the first use, and the DON stated she expected staff to follow the doctor’s order and prime the pen with 2 units before administering the ordered dose. The manufacturer’s guideline for Novolog reflected that small amounts of air may collect in the cartridge during normal use and instructed staff to turn the dose selector to 2 units to avoid injecting air and ensure proper dosing. The facility’s policies also stated medications are to be administered as prescribed and in accordance with written physician orders, with adherence to the rights of medication administration.
Failure to Clarify Postoperative Pain Medication Orders
Penalty
Summary
The facility failed to ensure Resident #42 received treatment and care in accordance with the oral surgeon’s postoperative instructions and the resident’s pain-related needs after oral surgery. Resident #42 was a cognitively intact female with diagnoses including dementia, major depressive disorder, heart disease, and high blood pressure. Her postoperative instructions indicated she was prescribed hydrocodone-acetaminophen and amoxicillin, and that pain management should include alternating the prescribed pain medication with ibuprofen 800 mg every 4 hours while awake, along with warm salt water rinses. Resident #42 returned to the facility after oral surgery with noted swelling to her mouth. She stated that LVN F argued with her about the medication orders and refused to listen when she said the oral surgeon’s instructions included ibuprofen and Tylenol for pain and swelling. Resident #42 said she kept asking for ibuprofen, but LVN F did not administer it because there was no order in the electronic medical record. The care plan included interventions for behavior management and monitoring after mouth surgery, but it did not include interventions for pain management after the oral surgery. During interview, LVN F acknowledged she knew the postoperative instructions indicated ibuprofen as needed, but she did not give it because there was no order in the EMR. She stated she should have called the doctor to clarify the medications Resident #42 was requesting, but said she did not have time. The DON and Administrator both stated that the postoperative instructions should have been clarified with the doctor and that failure to do so could have caused increased swelling or pain and placed the resident at risk of discomfort. The facility’s Physician’s Orders policy stated the nurse will review the order and contact the prescriber for clarifications if needed.
Fall Mat Not in Place for Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure Resident #2’s environment was free of accident hazards and that she received adequate supervision and assistance devices to prevent accidents. Resident #2 was a female with diagnoses including dementia, bipolar disorder, and high blood pressure. Her quarterly MDS showed a BIMS score of 4, indicating severely impaired cognition, and she required total staff assistance for bathing, toileting, and transfers, moderate assistance for bed mobility, and setup for eating. Her care plan identified her as a fall risk with fall mats to be kept at bedside while she was in bed, and her order summary included fall mats at bedside every shift for falls. Record review showed Resident #2 had fallen from her bed to the fall mat the day before the observation. During an observation, she was lying in bed in her room, with the right-side floor mat on the floor next to the bed and the left-side mat not in place; the left-side mat was standing against the bed. An LVN stated the fall mats were expected to be on the floor on both sides of the bed and said it was possible CNAs changed her in bed and forgot to replace the left-side mat. The LVN, DON, and Administrator each stated nurses and CNAs were responsible for ensuring the fall mats and other interventions were in place, and the DON and Administrator said the failure to have both mats in place placed the resident at risk for falls with injuries.
Missed Eye Drops and Improper Insulin Pen Preparation
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident for two residents reviewed for medications. One resident with a diagnosis including detachment of the retina and macula of the left eye had an active physician order for Refresh Tears Ophthalmic Solution 0.5% to be instilled in both eyes twice a day for dry eyes. The Medication Administration Record showed the eye drops were not administered on 03/10/26, and there was no documented rationale in the progress notes for the missed dose. During observation on 03/11/26, the resident was sitting in a recliner rubbing his eyes with a tissue and stated his eyes were stinging. He said he did not receive his eye drops the prior night or that morning. Later that morning, he said he had received his eye drops and his eyes felt better. The nurse who worked that shift said she did not recall giving the eye drops and believed she forgot because it was a busy night. The DON stated nurses were responsible for giving medications according to orders and that she identified the missed eye drop dose through review of the prior day’s medications. A second resident with Type 2 diabetes mellitus had an active order for Novolog FlexPen to be injected as per sliding scale before meals and at bedtime. During observation, an LVN prepared and administered the insulin without priming the pen first. The LVN stated she had never primed the insulin pen before administering insulin. The pharmacist consultant stated the pen should be primed with 2 units for first use, and the manufacturer’s instructions reflected that air may collect in the cartridge and the dose selector should be turned to 2 units to ensure proper dosing. The DON and Administrator both stated the pen should be primed before administration.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent. Surveyors found a 10% medication error rate based on 2 errors out of 30 opportunities, involving 2 of 6 residents reviewed for medication administration. One error involved Resident #47, a female with COPD and moderately impaired cognition, whose active order was for Albuterol HFA Sulfate Inhalation Aerosol Solution 2 puffs every 6 hours for COPD. During observation, LVN A gave the resident only 1 puff, handed her water to rinse her mouth, and left the room before the second puff was given. When questioned, LVN A stated the resident should have received 2 puffs and then returned to administer the second puff, explaining she had not walked the resident through the inhaler steps because the surveyor was present. The second error involved Resident #7, a female with Type 2 diabetes mellitus and intact cognition, who had an active order for Novolog FlexPen 1 unit subcutaneously before meals and at bedtime. During observation, LVN A prepared the insulin pen, attached the needle, and turned the dose knob to 1 unit, then administered the injection without priming the pen first. LVN A stated she had never primed the insulin pen before administering insulin. The pharmacist consultant stated the pen should be primed with 2 units for the first use, and the DON stated her expectation was that the insulin pen be primed with 2 units before resetting to the ordered dose and administering it. The report also reflected the facility’s policies and manufacturer guidance. The Novolog manufacturer instructions stated that small amounts of air may collect in the cartridge and that the dose selector should be turned to 2 units to avoid injecting air and ensure proper dosing. The facility’s medication administration policy stated medications are to be administered as prescribed and in accordance with written physician orders, with adherence to the 6 rights of medication administration, including the right dose and right time.
Failure to Honor Resident Food Dislike
Penalty
Summary
The facility failed to ensure Resident #54 received food that accommodated her stated dislike of corn. Resident #54 was an elderly female admitted with a diagnosis of Alzheimer's disease. Her quarterly MDS reflected that she usually made herself understood, usually understood others, and had a BIMS score of 4, indicating severely impaired cognition. She was independent with eating, and her care plan identified her as at risk for unplanned weight loss or gain and included interventions to determine food preferences and provide them within dietary limitations. Record review showed Resident #54's lunch meal ticket listed corn as a dislike, but on 03/10/26 at 12:46 p.m. she was served corn. During the observation, Resident #54 stated she could not have corn due to diverticulitis. Staff interviews reflected that the cook, nurses, and dietary staff were expected to check tray cards and ensure dislikes were honored, but [NAME] B stated she was unaware of the dislike and had not reviewed the meal ticket before preparing the tray. The Dietician, Dietary Manager, DON, and Administrator all stated resident food dislikes were expected to be followed, and the facility policy stated mealtimes could be adjusted per resident preference and food choices not including all food groups would be addressed in the care plan.
Missed Ordered Health Shake
Penalty
Summary
The facility failed to ensure that Resident #38 received a prescribed health shake with her meal. Resident #38 was a [AGE]-year-old female with diagnoses including malnutrition, dementia, and dysphagia. Her quarterly MDS indicated she was severely cognitively impaired, required assistance with multiple activities of daily living, and needed set up for eating. Her physician orders directed a pureed texture, regular consistency diet with divided plate, no straws, and a house supplement with meals, and her care plan directed staff to provide and serve the diet and supplements as ordered. During an observation, Resident #38 was being assisted with lunch and her tray card indicated a health shake with meals, but no health shake was on the tray. CNA G confirmed the shake was missing and said she was not aware who served the tray. The Dietary Manager verified the shake was not on the tray and stated the new Dietary Aide had missed the order. Dietary Aide E said she was responsible for ensuring health shakes were on the tray and believed she overlooked the tray card. LVN A said she checked lunch trays and knew the resident was supposed to have a health shake for weight loss, and the DON and Administrator stated the dietary staff and nursing staff were both responsible for ensuring ordered supplements were served.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents reviewed for infection control. Resident #4 was an [AGE] year-old male who re-admitted to the facility with a diagnosis including non-ST elevation myocardial infarction. His MDS admission assessment indicated he was able to make himself understood and understood others, and his BIMS score was 14, indicating intact cognition. He was occasionally incontinent of bladder and often incontinent of bowel, and he had MASD to the right and left buttock. His care plan identified actual impairment to skin integrity related to fragile skin and risk for frequent infections, with interventions to follow facility protocols for treatment and to monitor, document, and report signs and symptoms of infection to open areas. Resident #4's order summary on 3/12/2026 included enhanced barrier precautions every day and night shift and wound care orders for the left and right buttock to cleanse with Hibiclens, pat dry, apply zinc, and leave open to air. During an observation and interview on 3/12/2026 at 2:25 PM, the Wound Care Nurse performed wound care for Resident #4 and did not wear a gown. An EBP sign was observed on the outside of the door and supplies were at the doorway. The Wound Care Nurse stated she did not wear a gown because the order was new and she forgot, and stated it was important to follow the ordered enhanced barrier precautions to prevent the spread of infection. The DON stated she expected nurses and anyone involved with patient care to follow enhanced barrier precautions when ordered, and the Facility Administrator stated she expected all orders to be followed, including EBP orders.
Failure to Follow Designated Smoking Area Policy
Penalty
Summary
The facility failed to establish and follow smoking policies in accordance with applicable Federal, State, and local laws and regulations regarding smoking, smoking areas, and smoking safety, including consideration of nonsmoking residents. During an observation on 03/12/2026 at 11:38 AM, Dietary Aide H was seen smoking a cigarette on the sidewalk in front of the facility that led to the kitchen's back door. She extinguished the cigarette on the ground in the dirt and then went inside the kitchen. During an interview later that day, Dietary Aide H said she sometimes smoked in her truck or in the rocking chairs in front of the facility, and said she was not supposed to smoke in the residents' designated smoking area. She also said that if she was outside of the facility, she could smoke anywhere. The Administrator stated that the designated smoking area was across from the dining area and was where staff and residents were expected to smoke for safety. The Administrator said staff should not smoke on the sidewalk leading to the kitchen back door because it was a safety risk and did not provide a homelike environment to residents. The Human Resources Coordinator said new employees were shown the designated smoking area during orientation and that the staff smoking area was the same as the residents' smoking area. The facility's undated Smoking Policy stated that residents and employees are prohibited from smoking in any of the facility's buildings except in the designated smoking area, that employees, medical staff, residents, and visitors must smoke in the designated outdoor area only, and that they receive instruction on the smoking policy upon employment or admission.
Failure to Honor Resident Choice for Daytime Showers
Penalty
Summary
The facility failed to honor a resident’s right to make choices about significant aspects of her daily life, specifically her bathing schedule. A female resident with early-onset Alzheimer’s disease, severe cognitive impairment (BIMS score of 3), muscle weakness, gait and mobility abnormalities, lack of coordination, and hypertension was dependent on staff for showering and bathing. Her comprehensive care plan identified a self-care deficit and need for staff assistance with showering but did not document her shower preferences. Facility shower assignment records showed she was scheduled for showers on the 6 p.m.–6 a.m. shift three days per week, and during the review period she received bed baths late at night between approximately 10:18 p.m. and 11:39 p.m. instead of showers. The resident’s family member reported that over the last month the resident had missed several showers because the aide arrived so late in the evening that the resident was already ready to stay in bed, resulting in bed baths being provided instead of showers. The family member stated the resident’s hair had not been washed in over two weeks due to receiving bed baths rather than showers. The family member also reported that they had requested multiple times that the resident’s scheduled shower time be moved to the day shift, and that the ADON and DON responded they would try to provide day-shift showers if time allowed, otherwise the resident would continue to receive showers in the evening. Observation of the resident showed her hair was greasy, limp, and clumped together. Staff interviews confirmed awareness of the family’s request and the facility’s reliance on a standardized bathing schedule based on room location and hall assignment. CNA A stated that the resident’s family wanted the resident to be first on the 6 p.m. shift, but due to the shower schedule, the resident’s end of the hall was typically reached around 11 p.m., and that although residents should receive showers at their requested times, not everyone could have a day-shift shower. The DON acknowledged knowing of the family’s request for day-shift showers but stated the facility followed a standard bath schedule by hall and did not offer to move the resident to a different hall to accommodate the request. The ADON similarly stated that the facility used a standardized bathing schedule based on room location and that, due to this, the resident was showered on the night shift, with some showers provided during the day only when day-shift staff were able. The Administrator stated that if a family requested a day-shift shower, it should be person-centered and scheduled during the day, and that honoring residents’ choices was important, but she was not aware of this specific request.
Failure to Recognize and Address Repeated Shower-Schedule Complaints as Grievances
Penalty
Summary
The deficiency involves the facility’s failure to recognize and process repeated complaints about a resident’s shower schedule as formal grievances and to make prompt efforts to resolve them. A female resident with early-onset Alzheimer’s disease, severe cognitive impairment (BIMS score of 3), muscle weakness, gait and mobility abnormalities, lack of coordination, and hypertension was dependent on staff for showering and bathing. Her comprehensive care plan identified a self-care deficit and need for staff assistance with showering but did not document her shower preferences. The facility maintained a standard bathing schedule based on hall location, which placed this resident’s showers on the night shift. Over the course of about a month, the resident’s family member reported that the resident missed several showers because the aide arrived late in the evening when the resident was already ready to stay in bed, resulting in bed baths instead of showers. The family member stated the resident’s hair had not been washed in over two weeks due to receiving bed baths rather than showers. On observation, the resident’s hair appeared greasy, limp, and clumped together. The family member reported having requested multiple times that the resident’s scheduled shower time be moved to the day shift to accommodate her sleep schedule and stated these requests were made specifically to the ADON and discussed with the DON, who responded that they would try to provide day-shift showers if time allowed, otherwise the resident would continue to receive showers in the evening. Despite these repeated requests, review of the grievance logs showed no entry for a grievance from the resident’s family member. The DON acknowledged awareness of the family member’s request and stated the ADON and other staff had brought the matter to her attention on different occasions, but she did not consider it a grievance because of the facility’s standard bathing schedule and did not offer a room move to another hall to accommodate day-shift showers. The ADON confirmed the family member had requested day-shift showers more than once, stated she was unsure of the facility’s grievance process, and admitted she did not document the requests for follow-up, instead only discussing them in morning meetings. The Administrator, who was responsible for the grievance log and follow-up, indicated that if these requests had been documented as a grievance, she would have been aware and able to address the issue. The facility’s written grievance policy required that residents be allowed to voice grievances without reprisal and that the facility make prompt efforts to resolve grievances, but the policy was not followed in this case, as the family’s repeated complaints were not entered or processed as grievances.
Unlocked Treatment Cart and Improper Storage of Wound Cleanser
Penalty
Summary
Surveyors identified a deficiency related to medication storage and security involving a treatment cart on Hall A. During an observation at 10:46 a.m., the treatment cart was found unlocked and unattended, with a wound cleanser bottle sitting on top of the cart. The cart could be opened by the surveyor, and prescription triamcinolone cream tubes were found in the top drawer. Residents and staff were observed in the vicinity of the unlocked cart, and no staff noticed or intervened when the surveyor opened it. The facility’s written policy on medication storage stated that medications and biologicals are to be stored safely, securely, and properly, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that potentially harmful substances must be clearly identified and stored in a locked area separate from medications. In interviews, the Treatment Nurse stated she usually locked the treatment cart because it contained items and some medications, including wound cleanser and creams, that could be potentially dangerous if ingested by a resident. She reported that she had stepped into the shower room to assist an aide with a resident and did not take the time to put the wound cleanser away or lock the treatment cart before leaving it unattended. The Administrator stated she expected the Treatment Nurse to keep the treatment cart locked at all times to prevent accidents such as a resident drinking or spraying a harmful substance into their eyes. The DON stated she expected the treatment cart to be either under the direct supervision of the Treatment Nurse or locked at all times and reported that she conducted daily walks through the facility to check that medication and treatment carts remained locked.
Failure to Promptly Communicate Abnormal Urine Culture Results to Physician
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify and follow up with the ordering physician regarding abnormal urine culture and sensitivity results for one resident. The resident was an elderly female with cerebrovascular disease, candidiasis, muscle weakness, gait abnormalities, and dementia, with a severely impaired BIMS score and care plan indicating dependence for toileting and a self-care deficit. Her care plan also documented prophylactic antibiotic therapy for recurrent UTIs, but without listed interventions. On 12/24, a progress note documented increased agitation and exit-seeking behaviors, and the physician ordered a urinalysis with culture and sensitivity. The specimen was collected on 12/25 using sterile technique. On 12/27, progress notes showed that urinalysis results were received and sent to the physician, while the culture and sensitivity were still pending. That same day, the resident triggered alarms attempting to exit the facility and was admitted to the secured unit, with the ADON receiving her medications and urinalysis results. On 12/28, documentation indicated increased confusion, continued elopement attempts, and feces on the resident’s hands and bedding. On 12/29 at 1:32 p.m., the urine culture and sensitivity results were reported as abnormal and positive for E. coli. However, the 24-hour report for that date did not show that the lab results were faxed to the physician or that follow-up was required, and the resident’s progress notes for that date did not include the culture and sensitivity results. On 12/30, a progress note documented that the physician was notified of the urine culture and sensitivity results that had been received the previous day, with instructions to follow up with the resident’s urologist and no new orders at that time. The facility documented multiple messages left with the on-call agent and a fax of the lab results to the urologist. Additional notes that day indicated the resident continued on Keflex 250 mg daily as UTI prophylaxis and that a family member requested transfer to the hospital for further evaluation. Interviews with the family member, ADON, Regional Corporate Compliance, and Administrator confirmed that the lab results were not entered on the 24-hour report on the day they were received, that all nurses were responsible for lab follow-up, and that failure to document and communicate labs through the established processes could result in missed follow-up. The facility’s policy stated that when test results are reported, a nurse must review them and, if unable to complete the reporting and documentation process, another nurse should coordinate the procedure, which did not occur as required in this case.
Failure to Perform Hand Hygiene and Glove Change During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during incontinent care for one resident. The resident was an older female with diagnoses including congestive heart failure, gait and mobility abnormalities, chronic pulmonary edema, Type 2 diabetes mellitus, muscle weakness, and lack of coordination. A comprehensive MDS showed she had moderately impaired cognition with a BIMS score of 10, was dependent on staff for toileting, and required maximum assistance for showering and bathing. Her care plan documented a self-care deficit and the need for staff assistance with toileting. On the observed date and time, two CNAs entered the resident’s room to provide incontinent care, washed their hands, and applied gloves. During the care, both CNAs removed the resident’s soiled brief but did not change their soiled gloves or perform hand hygiene before applying barrier cream. In subsequent interviews, both CNAs acknowledged they were supposed to remove soiled gloves and perform hand hygiene between steps of perineal care and stated they failed to do so because they forgot or were nervous. The DON and Administrator both confirmed that facility expectations and policy required hand hygiene between glove changes and changing soiled gloves prior to applying barrier cream, and that these practices were important to prevent urinary tract infections, sepsis, and the spread of disease. Facility policy on perineal care required doffing and discarding visibly soiled gloves and performing hand hygiene before and after glove use.
Failure to Ensure RN Coverage on a Holiday
Penalty
Summary
The facility failed to ensure there was a registered nurse (RN) on duty for 8 consecutive hours on Thanksgiving Day, 11/28/24. This deficiency was identified through interviews and record reviews. The RN time sheets confirmed the absence of an RN on that day. During interviews, the Director of Nursing (DON) admitted she did not work on Thanksgiving Day and was unsure if any other RN was assigned to work. The Administrator acknowledged the lack of RN coverage and accepted responsibility for ensuring RN coverage. It was also noted that the facility did not have a policy regarding RN coverage, although they claimed to follow regulations.
Failure to Coordinate PASRR Assessments with Hospice Representative
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program effectively, resulting in a deficiency for one of the six residents reviewed. Specifically, the facility did not include the hospice representative in the Interdisciplinary Team (IDT) meetings for a resident with intellectual and developmental disabilities, which were necessary for requesting specialized physical therapy (PT) and occupational therapy (OT) services. The absence of the hospice representative in these meetings led to a lack of required information being submitted to the PASRR Unit, resulting in the denial of PT services and potential delays in OT services. The resident in question was a female with a history of seizures and intellectual disabilities, who had been marked as needing specialized services under the PASRR program. Despite requests from the PASRR Unit for additional information to authorize these services, the facility failed to ensure the hospice representative's participation in the IDT meetings, as required. This oversight was acknowledged by the facility's staff, including the MDS Nurse and the Director of Rehabilitation (DOR), who noted the scheduling issues and the potential for service delays or non-payment due to the incomplete meetings.
Failure to Address PASRR Positive Status in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents with PASRR positive status, which is required to address their medical, nursing, and mental and psychosocial needs. Resident #11, a female with schizoaffective disorder and bipolar type, was admitted with a PASRR positive status for mental illness and intellectual disability. Despite being on medications like Abilify and Olanzapine for her condition, her care plan did not reflect her PASRR positive status, which could lead to missed services. Resident #28, a female with cerebral palsy and diabetes, was also identified as PASRR positive. However, her care plan failed to address her PASRR status, potentially leading to a lack of necessary services. Similarly, Resident #34, a female with anxiety, had no care plan addressing her PASRR positive status, despite having a prescription for Buspirone to manage her condition. Interviews with facility staff, including the MDS nurse, DON, ADON, and the Administrator, revealed that the responsibility for care planning PASRR positive status was assigned to the MDS nurse. However, it was acknowledged that the PASRR positive status was overlooked in the care plans of these residents. The facility's policy mandates the development of comprehensive care plans that include measurable objectives and timeframes, but this was not adhered to, resulting in potential missed services for the residents.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to ensure that residents were informed of services available and charges for those services, including those not covered under Medicare/Medicaid. Specifically, Resident #54 was not provided with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when discharged from skilled services, which is a document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services. This oversight was identified during a review of Resident #54's records, which showed that the resident was admitted with Medicare Part A for skilled nursing care, with coverage ending on 08/31/24, and continued on Medicaid services thereafter. However, there was no record of the SNF ABN being given to the resident's family or responsible party. Interviews and observations revealed that the MDS nurse was unaware of her responsibility for issuing the SNF ABN letters and was scheduled to receive training on the same day the deficiency was noted. Additionally, the facility's Administrator expressed uncertainty about the requirement to complete the SNF ABN form and planned to seek guidance from corporate for training. This lack of awareness and training among staff contributed to the failure to inform Resident #54's family or responsible party about the change in coverage, potentially placing residents at risk of being unaware of changes to the services provided.
Failure to Include Depression Diagnosis in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed for a newly admitted resident, specifically omitting the resident's diagnosis of depression and the prescribed antidepressant medication, Amitriptyline. The resident, an elderly male, was admitted with a diagnosis of depression and had a physician's order for Amitriptyline 25mg daily. However, the baseline care plan did not address these critical aspects of his care, which are essential for providing effective and person-centered care. Interviews with the Director of Nursing (DON) and the Administrator revealed that the responsibility for completing care plans lies with the nursing staff, and the baseline care plan should be informed by the resident's transfer papers. The DON acknowledged that the absence of a care plan addressing the resident's depression and medication could lead to inadequate monitoring of his condition. The facility's policy on baseline care plans emphasizes the importance of reflecting the resident's immediate needs and incorporating information from admission orders and discussions with the resident or their representative.
Expired Medications Not Removed from Medication Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not removing expired medications from a medication cart, specifically affecting Resident #4. The resident, a female with dementia and anxiety, was prescribed ABH gel, a compounded medication for anxiety and restlessness. The medication cart contained syringes of ABH gel with expiration dates that had passed, yet they were not removed from use. The oversight was discovered during a survey when it was noted that the syringes had expired 68 and 35 days prior, respectively. The issue arose from a misunderstanding of the expiration dates on the medication labels. The nurses, including LVN C, were checking the wrong expiration date on the medication labels, leading to the expired medications remaining on the cart. The facility's pharmacy had a practice of marking out the original expiration date when medications were compounded, but the hospice pharmacy that provided these medications did not follow this practice, contributing to the confusion. Despite the presence of expired medications, it was noted that LVN C had not administered the expired medication. Interviews with various staff members, including the DON, ADON, and the Pharmacy Consultant, revealed that the responsibility for removing expired medications lay with the nurses, with additional checks by the pharmacy consultant and nurse managers. However, due to the discrepancy in labeling, the expired medications were overlooked. The staff acknowledged that administering expired medication could result in reduced effectiveness, although it was not considered harmful. The facility's policy required expired medications to be submitted to the DON for destruction, but this procedure was not followed in this instance.
Gas Stove Maintenance Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the gas stove. During an observation, it was noted that one of the six burners on the stove did not light using the pilot light and could not be lit with a long lighter. This issue was reported to the maintenance supervisor, who acknowledged that the pilot light required cleaning at times. The maintenance supervisor later confirmed that he had cleaned the pilot light and removed a fan in the kitchen. The Administrator stated that there was no specific policy regarding equipment maintenance, but the expectation was for the stove to function properly.
Improper Handling of Resident Post-Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice after a fall. The resident, who had severe cognitive impairment and was on hospice care due to Alzheimer's disease, fell while attempting to walk from a sitting position. Despite the fall being witnessed by CNAs, the resident was improperly transferred back to her bed without being assessed by a nurse first. This action was contrary to the facility's protocol, which requires a nurse to assess a resident before any movement after a fall. The incident report indicated that the resident was initially assessed with no visible injuries, but later complained of pain in her right hip/thigh area. An x-ray confirmed an acute fracture of the proximal femur. Interviews with staff revealed that the CNAs moved the resident without notifying the nurse immediately, and the nurse was not informed of the fall until approximately an hour later. The CNAs admitted to transferring the resident improperly, and the nurse on duty did not perform a thorough assessment upon being informed of the fall. The facility's failure to follow proper procedures for assessing and handling a resident after a fall led to a delay in identifying a serious injury. The resident's condition required increased pain management and adjustments to her care plan, including the use of a low air loss mattress and a foley catheter for comfort. The incident highlights a breakdown in communication and adherence to protocol among the facility's staff, which could have placed the resident at risk of further harm.
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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) |
|---|---|---|---|---|
| Focused Care Of Gilmer | 0.9 mi | ★★★★★ | 19 | 2 |
| Legend Oaks Healthcare And Rehabilitation Center - | 12.6 mi | ★★★★★ | 14 | 0 |
| Truman W Smith Children's Care Center | 13.2 mi | ★★★★★ | 5 | 0 |
| Pine Tree Lodge Nursing Center | 15.9 mi | ★★★★★ | 19 | 2 |
| Avir At Pittsburg | 17.8 mi | ★★★★★ | 13 | 0 |
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