Gilman Healthcare Center

Inspectors wroteFailures at this level required more than one Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to ensure a resident who fell from a wheelchair while being transported by a staff member was assessed for potential head, cervical spine, or other injuries prior to being moved and failed to ensure the resident was safely transported in a wheelchair with required foot pedals for two (R2, R7) of ten residents reviewed for accident hazards and supervision on the sample list of 11. These failures resulted in R2 sustaining two acute C1 cervical spine fractures and left facial fractures. R2 expired at the hospital after the fall. R2's death certificate documents a contributing factor as Fall at Nursing Home and the manner of death as Accident. [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately assess and supervise a cognitively impaired resident for the use of an electric assisted standing recliner for one (R1) of three residents reviewed for accidents on the sample list of five. This failure resulted in R1 falling and receiving a left subdural hematoma and a nondisplaced fracture of the left frontal bone.

Inspectors wroteBased on record review and interview the facility repeatedly failed to ensure that a designated key member (Infection Control Preventionist) of the committee was present at their quarterly Quality Assurance (QA) meeting. This has the potential to affect all 56 residents that reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide Activities of Daily Living (ADL's) assistance, to maintain residents dignity for two of 25 residents (R25 and R46) reviewed for dignity on the sample list of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to routinely provide oral hygiene for one of one resident (R25) reviewed for oral care on the sample list of 25. Findings Include: The facility's Oral Care policy dated 4/2/24 documents it is the facility's practice to provide oral care to residents in order to prevent and control plaque-associated oral disease. R25's Medical Diagnoses List dated May 2024 documents R25 is diagnosed with Palliative Care, Depression, Alzheimer's Disease, Dementia, Mood Disorder, and Restlessness and Agitation. R25's Minimum Data Set, dated [DATE] documents R25 is severely cognitively impaired and requires substantial/maximum assist for oral hygiene. R25's Care Plan dated 5/23/24 documents R25 is not accepting of oral care and is verbally and physically abusive towards staff during this task. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a resident toilet and bed position remote control cable in a safe and repaired condition. These failures have the potential to affect three residents (R4, R14, R31) of four reviewed for safety in the sample list of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all mechanical lift slings were routinely assessed and replaced in accordance with manufacturer's instructions and facility policy. This failure resulted in a mechanical lift sling breaking during R1's transfer which caused R1 to fall from the mechanical lift and sustain head lacerations that required staple closure. This failure has the potential to affect seven additional residents (R2, R3, R4, R5, R6, R7, R8) of eight residents reviewed for mechanical lift transfers in the sample list of eight.

Inspectors wroteBased on observation, interview and record review, the facility failed to answer a call light timely for one of four residents (R4) reviewed for call lights/delay in care on the sample list of six. Findings Include: R4's MDS (Minimum Data Set) dated 8/21/23 documents R4 is alert and oriented. On 10/18/23 at 10:32 am, R4 stated it takes a long time for staff to answer R4's call light and explained that R4 had waited as long as an hour in the past for the call light to be answered. On 10/19/23 at 8:23 am, R4's call light was activated. At 8:30 am, V10 Scheduler walked by R4's room and did not answer the call light. R4 can be heard across the hall and approximately 20 feet away breathing hard and grunting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to perform timely toileting assistance for one of three residents (R4) reviewed for toileting on the sample list of six. Findings Include: R4's MDS (Minimum Data Set) dated 8/21/23 documents R4 is alert and oriented and requires assistance with toileting. On 10/19/23 at 8:23 am, R4's call light was activated. At 8:48 am, staff answered R4's call light then left the room. At 8:50 am, R4 stated, R4 was waiting for staff to toilet R4 explaining, I (R4) have to go bad and I have been waiting for them to take me since 8:10 am (40 minutes). At 8:55 am, V11 and V12 CNA's (Certified Nursing Assistant's) returned to R4's room to toilet R4. [...]

Inspectors wroteBased on observation and interview, the facility failed to properly perform incontinence care for one of three residents (R2) reviewed for toileting and incontinence care on the sample list of six.

Inspectors wroteBased on interview and record review, the facility failed to prevent two episodes of physical abuse between residents for five of five residents (R1, R2, R8, R9 and R10) reviewed for abuse on the sample list of 10. This resulted in R1 hitting R2 on top of the head with a metal cane then R1 throwing a cup and eating utensils at R2, hitting R2 in the arm, causing psychosocial harm for R2 and R9, along with a hematoma to the top of R2's head. Findings Include: The facility's Abuse, Neglect and Exploitation Policy dated 2/28/23 documents, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop care plans and implement fall prevention interventions for residents at risk for falls and failed to thoroughly investigate a fall and implement appropriate post fall interventions for three of three residents (R5, R6 and R7) reviewed for falls on the sample list of 10. These failures resulted in R5 having multiple falls resulting in a compression fracture of L5. Findings Include: The facility Fall Prevention Program dated June 2023 documents the fall prevention program will be implemented to ensure all resident's safety in the facility whenever possible. This program should include a measure that determines each resident's needs by assessing the risks for falls and implementing appropriate interventions to provide the necessary supervision, and assistive devices are utilized as necessary. [...]

Inspectors wroteBased on interview and record review, the facility failed to operationalize their Abuse, Neglect and Exploitation Policy for reporting and investigating abuse allegations for five of five residents (R1, R2, R8, R9 and R10) reviewed for abuse on the sample list of 10. Findings Include: The facility Abuse, Neglect and Exploitation Policy dated 2/28/23 documents it is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse between two residents (R1, R2) reviewed for abuse on the sample list of 10. Findings Include: On 10/12/23 at 12:23 pm, V12 LPN (Licensed Practical Nurse) stated V12 was told by V8 Activity Aide/CNA (Certified Nursing Assistant) that R1 threw R1's cups at R2 and hit R2 in the arm. On 10/12/23 at 12:39 pm, V8 stated last week when V8 was in the dining room, V8 walked by R2's table and R2 reported that R1 had just thrown a glass and silverware at R2, hitting R2 in the arm. V8 stated V8 considered R1's actions to be abusive towards R2, so V8 reported the situation to administration and wrote up a witness statement. V8's witness statement dated 10/5/23 documents R2 reported to V8 that R1 had just thrown a cup and silverware from R1's table to R2's; [...]

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of physical abuse between two residents (R1, R2) reviewed for abuse on the sample list of 10. Findings Include: On 10/12/23 at 12:39 pm, V8 stated last week while in the dining room, R2 reported to V8 that R1 threw a glass and silverware at R2, hitting R2 in the arm. V8 stated V8 reported the situation to administration and wrote a witness statement due to V8 considering R1's actions to be abusive in nature toward R2. V8's witness statement dated 10/5/23 documents R2 reported to V8 that R1 had just thrown a cup and silverware from R1's table to R2's; of which the cup hit R2 on R2's upper, outer left arm. R2 stated R2 was not hurt and apparently no one else was hurt at the table as a result of R1's action. [...]

Inspectors wroteFailures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to develop a care plan and interventions for a resident (R4) who is at high risk for developing pressure ulcers and has a history of pressure ulcers. The facility failed to implement pressure relieving interventions, routinely assess resident's skin, identify a pressure ulcer, assess a pressure ulcer upon identification, report a pressure ulcer to the wound nurse and physician, implement a treatment, and ensure open wounds were covered for one (R4) of five residents reviewed for pressure ulcers and repositioning in the sample list of five. These failures resulted in R4 developing a pressure ulcer of the right buttock that deteriorated into a Stage 4 pressure ulcer without treatment nor interventions. [...]

Inspectors wroteBased on interview and record review the facility staff failed to provide safety for one resident (R21) when using the mechanical lift for transfer for one (R21) of four residents reviewed for accidents in a sample of 23. This failure resulted in R21 falling onto the floor out of of a mechanical lift sling during a transfer requiring a emergency department evaluation and sustaining a facial laceration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to designate a qualified director of food and nutrition services. This failure has the potential to affect 59 out of 60 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement procedures to protect food products from cross contamination by leaving utensils inside bulk food storage tubs. This failure has the potential to affect 59 out of 60 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to notify a resident's representative in writing of the facility's Bed Hold Policy when a resident was transferred to the hospital. This failure affected one of two residents (R16) reviewed for hospitalizations on the sample list of 23. Findings Include: On 7/13/23 at 4:00 PM V1 Administrator and V2 Director of Nurses both confirmed the facility attaches the Bed Hold Paperwork to the Resident Transfer paperwork and sends them with a resident when they are sent to the emergency room however, when applicable they do not provide a written copy of either document upon transfer to the resident's representative. The Nurses Note dated 6/16/2023 documents R16 was transported to the emergency room for altered mental status via ambulance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer enteral tube feeding in a safe manner to resident. The facility failed to label an enteral tube feeding with resident name, product name, date and time prepared, in accordance with facility policy. This failure affects one resident (R209) out of one reviewed for gastrostomy tube feedings on the sample list of 23.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain a physician's order for a CPAP (Continuous Positive Airway Pressure) treatment for one (R50) of one resident reviewed for CPAP/BIPAP treatments in the sample list of 23.

Inspectors wroteBased on observation and interview, the facility failed to ensure packaged food items (milks) were not expired when served to residents. This failure affects four residents (R26, R46, R48, and R51) out of 10 reviewed for dining on the sample list of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a clean, homelike environment by leaving feces on the floor and toilet, and soiled linens on the floor for two (R49, R303) of two residents reviewed for a homelike environment in a sample list of 27.

Inspectors wroteBased on record review and interview, the facility failed to address the use of antipsychotic medications in a resident's plan of care. This failure affects one resident (R48) out of five reviewed for unnecessary medications on the sample list of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to implement fall prevention interventions according to a resident's care plan. This failure affects one resident (R28) out of six reviewed for accidents on the sample list of 27.

Inspectors wroteBased on interview and record review, the facility failed to ensure a PRN (as needed) anti-anxiety medication was discontinued after 14 days per the physician's directions. This failure affects one resident (R48) out of five reviewed for unnecessary medications on the sample list of 27.