Gilmer Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 3 residents (Resident #9, Resident #12, and Resident #31) reviewed for resident rights. The facility failed to ensure CNA K did not stand over Resident #9 and Resident #31 while assisting them to eat on 03/11/2026. The facility failed to ensure CNA K was not on her personal cell phone when assisting Resident #9 with eating and while sitting with Resident #12 on 03/11/2026. These failures could place residents at risk of decreased self-worth, loss of dignity, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 3 of 6 residents (Resident's #52, #1 and #39) reviewed for care plans.1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure menus met the nutritional needs of residents in accordance with established guidelines were followed for 1 of 1 meal (the lunch meal) reviewed for nutritional adequacy. The facility did not ensure 2 fish tacos were given to residents on 03/10/26. This failure could place residents at risk of a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility did not ensure:1. Food items were labeled and dated.2. Hair restraints were worn. 3. Personal items were properly stored. 4. The dome covers, bowls, and trays were not stacked with water pooled between them. 5. The pureed mixer top was free from food debris. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to collaborate with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving hospice services for 3 of 6 residents (Resident #10, Resident #12, and Resident #27) reviewed for hospice services. 1. The facility failed to obtain and ensure Resident #10's most 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 part of the current clinical record. 2. The facility failed to obtain Resident #27's most current interdisciplinary group notes. 3. The facility failed to obtain Resident #12's most current Hospice Certification of Terminal Illness and Hospice Plan of Care. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the residents had a right to secure and confidential personal medical records and privacy during medical treatments for 1 of 22 residents (Resident #5) reviewed for resident rights. The facility did not ensure the Treatment Nurse used a secure telephonic device to communicate about Resident #5's medications with the facility Medical Director. This failure could place residents at risk for diminished quality of life, loss of dignity, self-worth and breach of confidentiality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 22 residents (Resident #42) reviewed for resident abuse. The facility failed to ensure Resident #42 was not verbally abused by LVN F on 03/10/26, when she told Resident #42 that's why you are in a nursing home. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit neglect, and abuse of residents, for 1 of 22 residents (Resident #42) reviewed for abuse. The facility failed to follow their policy to report to HHSC within 2 hours of an abuse allegation, when Resident #42 alleged that LVN F argued with her about her medications and told Resident #42 that's why you are in a nursing home. This failure could place residents at risk of abuse, neglect, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to make a comprehensive assessment of each residents' needs, strengths, goals, life history, and preferences within 14 calendar days after admission for 1 of 22 residents (Resident #19) reviewed for timeliness of assessments. The facility failed to complete Resident #19's admission MDS assessment, with an assessment reference date of 03/03/2026, within 14 days of admission. This failure could place residents at risk of not having their needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 1 assessment accurately reflected the resident's status for 2 of 5 residents (Resident #2, Resident #6) reviewed for PASRR Level 1 screenings. 1. The facility failed to ensure the PASRR Level 1 screening for Resident #2 was completed and submitted upon admission date of 08/14/24. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #6. The PASRR 1 Level screening did not indicate a diagnosis of mental illness PTSD (post-traumatic stress disorder), although the diagnosis was present upon admission date on 05/01/25. These failures could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 2 residents (Resident #63) reviewed for baseline care plans. The facility failed to address Resident #63's dialysis on his baseline care plan. This deficient practice could place residents at risk of missed care or not receiving necessary care and services.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the services provided, as outlined by the comprehensive care plan, met professional standards of quality, for 2 of 6 residents (Residents #47, and #7) reviewed for services provided to meet professional standards. 1. The facility did not ensure LVN A administered 2 puffs of Albuterol (medication used to prevent and treat wheezing, difficulty breathing, chest tightness and coughing) HFA Sulfate Inhalation Aerosol Solution instead of 1 puff to Resident #47. 2. The facility did not ensure LVN A primed Resident #7's Novolog FlexPen (insulin medication) according to the manufacturer's instructions. These failures could place residents at risk of inaccurate drug administration and not receiving the care and services to meet their individual needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, based on comprehensive assessment of resident, that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice for 1 of 6 residents (Resident #42) reviewed for quality of care. The facility failed to ensure LVN F clarified orders for ibuprofen (a non-steroidal anti-inflammatory drug used to decrease pain and swelling), after Resident #42 had oral surgery on 03/10/26, and her postoperative recommendations indicated to administer ibuprofen for pain and swelling. This failure could place residents at risk of a delay in treatment for the residents' conditions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #2) reviewed for accidents and hazards. The facility failed to ensure Resident #2's fall mat on her left side of her bed was in place on 03/11/26 while she was in her room lying in bed. This failure could place residents at risk of accidents that could result in serious injury, harm, impairment, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 6 residents (Resident #'s 7 and 39) reviewed for medications.1. The facility failed to administer Refresh Tears Ophthalmic Solution 0.5 % (quickly alleviates dryness, irritation, and discomfort by replenishing moisture to the eyes) for Resident #39 on 03/10/26.2. The facility did not ensure LVN A primed Resident #7's Novolog FlexPen (insulin medication) according to manufacturer's instructions. This failure could place residents at risk for not receiving the therapeutic effects of their medications to include a diminished health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 10%, based on 2 errors out of 30 opportunities, which involved 2 of 6 residents (Residents #47 and #7) reviewed for medication administration. 1. The facility did not ensure LVN A administered 2 puffs of Albuterol (medication used to prevent and treat wheezing, difficulty breathing, chest tightness and coughing) HFA Sulfate Inhalation Aerosol Solution instead of 1 puff to Resident #47. 2. The facility did not ensure LVN A primed Resident #7's Novolog FlexPen (insulin medication) according to the manufacturer's instructions. These failures could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 1 resident (Resident #54) reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to ensure Resident #54's preference for dislike of corn was honored on 03/10/26. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received it and the facility provided food prepared in a form designed to meet individual needs for 1 of 6 residents (Resident's #38) reviewed for food and drinks. The facility failed to ensure Resident #38, received her health shake on 03/10/26. This failure could place residents at risk for weight loss, and unmet nutritional needs. Findings Included:Record review of Resident #38's face sheet, dated 03/16/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #38 had diagnoses which included malnutrition (a critical health condition caused by a diet lacking, or excessive in, nutrients and calories, leading to deficiencies, obesity, or chronic health issues), dementia (loss of memory), and dysphagia (problem swallowing). [...]

Inspectors wroteBased on observation, interview and record review 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 (Resident #4) reviewed for infection control. The facility failed to ensure the Wound Treatment Nurse donned a gown when she provided wound care to Resident #4 on 3/12/2026. This failure could place residents at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also took into account nonsmoking residents for 1 of 1 facility reviewed for smoking policies. The facility failed to ensure Dietary Aide H followed the smoking policy, when she did not use the facility's assigned smoking area to smoke on 03/12/2026. This failure could place residents at risk of an unsafe smoking environment and an increased risk of injury related to smoking.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 6 residents (Resident #1) reviewed for self-determination. The facility failed to ensure Resident #1 was provided with showers during the day shift instead of showers at nighttime per Resident #1's family's request. This failure could place residents at risk of being denied the opportunity to exercise his or her own rights regarding the things that were important in their life and decrease their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly resolve grievances for 1 of 6 residents (Resident #1) reviewed for grievances. The facility failed to ensure a grievance was filed when Resident #1's family member reported to the ADON a request for Resident #1's showers be given on the day shift to accommodate Resident #1's sleep schedule was not honored. This failure could place residents at risk for grievances not being addressed or resolved promptly.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 3 medication carts (Treatment Cart) reviewed for pharmacy services. 1. The facility failed to ensure the Treatment Cart was properly secured when it was left unattended on 01/29/26. 2. The facility failed to ensure the wound cleanser left on top of the Treatment Cart was properly secured on 01/29/26. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify and follow-up with the ordering physician regarding laboratory results outside of clinical reference range for 1of 6 residents (Resident #3) reviewed for laboratory services. The facility failed to notify the physician promptly on 12/29/2025 at 01:32 p.m. of Resident #3's Urine Culture and Sensitivity laboratories results. This failure could place residents at risk of not receiving and managing medications at a therapeutic level.

Inspectors wroteBased on observation, interview, and record review, 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 6 residents (Resident #2). The facility failed to ensure CNA B and CNA C changed their gloves and performed hand hygiene after removing Resident #2's soiled brief and before applying barrier cream when they provided incontinent care on 01/29/26. This failure could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure there was an RN for 8 consecutive hours 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility did not have RN coverage for 8 consecutive hours on 11/28/24 (Thanksgiving Day). This failure could place residents at risk of lack of nursing oversight and a higher level of care.

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 6 residents reviewed for PASRR services. (Resident #1) * The facility did not have Resident #1's hospice representative present for the PASRR IDT meeting dated 04/09/24 requesting specialized PT services. * The facility did not have Resident #1's hospice representative present for the PASRR IDT meeting dated 10/25/24 requesting specialized OT services. These failures could affect the residents with intellectual and developmental disabilities by placing them at risk of a delay in or not receiving specialized services that would enhance their highest level of functioning.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 15 residents. (Resident #11, #28, and #34) The facility failed to develop a care plan for Resident #11, #28, and #34's PASRR (Preadmission Screening and Resident Review) positive status. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure each resident was informed before or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #54) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #54, was given a SNF ABN (a document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility. This failure could place residents at risk for not being aware of changes to the services provided.

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed for 1 of 2 residents reviewed for new admissions (Resident #108). The facility failed to include Resident #108's diagnosis of depression and antidepressant medication the baseline care plan. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) in 1 of 4 medication carts reviewed (Short Hall Nurse medication cart) (Resident #4's medication). A package of Resident #4's 14 one ml syringes filled with ABH gel (a combination medication of Ativan {antianxiety medication}, Benadryl, {medication that relieves symptoms of nausea, vomiting and dizziness, rash, and cough} and Haldol {an antipsychotic medication that calms you down}) for Resident #4 with an expiration date of 09/04/25 and a lot expiration date of 10/04/24, had been expired for 68 days and not removed from use. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition with the pilot light staying lit and allowing gas to leak. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.

Inspectors wroteBased on interviews and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 8 (Resident #1) residents reviewed for quality of care. The facility did not ensure Resident #1 was assessed by a nurse after a fall. Resident #1 was improperly transferred to her bed by CNA G and CNA H without first being assessed by the nurse, LVN E. The noncompliance was identified as PNC. The IJ began on 1/30/24 and ended on 2/2/24. The facility had corrected the noncompliance before the investigation began. These failures could place residents at risk of serious harm, and not receiving the necessary interventions to reach their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to 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 13 (Residents #7, #31, #208, #30, #39, #45, #32, #44, #28, #15, #16 , #34, #25 ) of 15 residents and 9 employees ( LVN B, MDS nurse, Dietary staff V, CNA D, Housekeeping Supervisor, Housekeeper Y, Housekeeper EE, CNA N, and CNA H ) out of 135 employees in the facility, 1 (RN DD) of 1 contract employees and 1 (clean cart) of 3 linen carts reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure Residents #208 and #31 were separated after Resident #31 tested positive for COVID on 10/23/23, and Resident #208 did not. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure a fan blowing toward the stove was free from dust like material. The facility failed to ensure the microwave was free from a light beige colored material dried to the number pad of the microwave. The facility failed to ensure the can opener blade was free from a rust-colored material. The facility failed to ensure 7 dozen boiled eggs with an expiration date of 10/25/2023 were not available for use. The facility failed to ensure the dishwasher aide was wearing a hair net. The facility failed to ensure a red cleaning bucket had sufficient sanitizing chemical for cleaning. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 6 of 19 residents (Resident #'s 207, 50, 19, 20, 34, and 33) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #207's comprehensive care plan addressed that she received olanzapine (antipsychotic medication). The facility failed to ensure Resident #50's siderails, and risk of dehydration were care planned. The facility failed to ensure Resident #19's siderail was care planned. The facility failed to ensure Resident #20's siderails were care planned. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 7 of 12 residents reviewed for quality of life. (Resident #'s 7, 11, 19, 20, 33, 34, and 50) The facility failed to provide facial hair removal/shaving for dependent female Resident #7. The facility failed to ensure Resident #'s 50, 33, 34, and 19 received their scheduled baths. The facility failed to ensure Resident #20's nails were clean and free of a brown colored material. The facility failed to ensure Resident #20 was free of facial hair. These failures could place residents who were dependent on staff to perform personal hygiene at risk of embarrassment, decreased self-esteem, or decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic drugs and PRN orders for psychotropic drugs were limited to 14 days for 4 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #'s 207, 106, 24, and 1). The facility failed to adequately monitor Resident #207's side effects and behaviors regarding her antipsychotic medication. The facility failed to follow Resident #207's hospital discharge orders for her antipsychotic medication. The facility failed to monitor Resident #106's side effects for the use of Sertraline (Zoloft) and Bupropion (Wellbutrin). The facility failed to obtain appropriate diagnosis for Resident #24's antipsychotic medication. Resident #1 continued to have a PRN order for Lorazepam 0.5mg after 14 days without an evaluation by the physician for continued treatment. [...]

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure the residents has the right to be informed of the risks and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred, for 2 of 5 residents (Resident #'s 24 and 106) reviewed for resident rights. 1. The facility failed to complete the psychotropic consent for Resident # 24's Risperidone (anti-psychotic) to treat Alzheimer's and Resident #106's Sertraline (antidepressant) and Buproprion (antidepressant) that treat depression. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide all necessary information and any other documentation to ensure a safe and effective discharge for 1 of 2 residents reviewed for discharge. (Resident #54) The facility failed to document Resident #54's reason for being discharged from the facility. These failures could place residents at risk for not receiving care and services to meet their needs upon discharge.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for 1 of 6 residents reviewed for baseline care plans. (Resident #106) The facility failed to develop a baseline care plan that addressed Resident #106's risk to fall, use of psychotropic medications, use of an assistive devices, abnormal gait, history of falls, unsteadiness of feet, and muscle weakness. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview, and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 4 (Resident #50) residents reviewed for care plan revisions. The facility failed to ensure Resident #50's care plan was updated when she moved from the secured unit to the general community. on 10/19/2023. TThe facility failed to ensure Resident #50's care plan was updated when she was no longer an elopement risk . These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for 2 of 9 residents (Resident #'s 19, and 106) reviewed for accidents and supervision. The facility failed to ensure Resident #19 was free from 2 bottles of wound cleanser, and one plastic medication cup with a white cream at her bedside. The facility failed to implement any interventions to prevent Resident #106's fall on 10/25/2023. These failures places residents at risk for injury and serious injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 2 of 2 residents (Resident #'s 21 and 50) reviewed for hydration. The facility failed to ensure Resident #21, and Resident #50 received adequate hydration. This failure could place residents at risk for dehydration, electrolyte imbalance, and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care was provided with professional standards of practice for 2 of 4 resident reviewed for quality of care. (Resident #6 and Resident #18) The facility failed to administer oxygen at 3 liters via nasal cannula as prescribed by the physician for Resident #6. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #18. These failures could place residents who receive respiratory care at risk for developing respiratory complications.

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to ensure correct installation, use and maintenance of bedrails for 3 of 3 residents (Resident #'s 19, 20, and 50) reviewed for bedrails. 1. The facility failed to assess Resident #s 19, 20, and 50 for the risk of entrapment from bed rails prior to installation. 2. The facility failed to review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation for Resident #'s 19, 20, and 50. 3. The facility failed to document the attempt of alternatives to meet Resident #'s 19, 20, and 50 needs. These failures could place residents at risk for entrapment with serious injury and even death.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #10) reviewed for hospice services. The facility failed to obtain Resident #10's physician's order for hospice services and the most recent hospice plan of care. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, and neglect for 3 of 18 residents reviewed for abuse and neglect (Resident #12, Resident #13, and Resident #14) in that: Resident #12 was abused when LVN C put her hand over Resident #12's mouth to stop her from screaming. LVN C also threatened to push Resident #12 into cold water if she did not stop screaming. Resident #13 was physically abused by Resident #12. Resident #12 slapped Resident #13 in the face. Resident #12 had a history of abusive behaviors. Resident #12 disliked Black people and targeted two Black residents on the secure unit, Resident #13, and Resident #14. An Immediate Jeopardy (IJ) situation was identified on 10/3/23 at 6:00 p.m. The IJ template was provided to the facility on [DATE] at 6:00 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement written polices and procedures to prohibit abuse by ensuring residents had the right to be free from abuse, and neglect for 3 of 18 residents reviewed for abuse and neglect (Resident #12, Resident #13, and Resident #14). Resident #12 was abused when LVN C put her hand over Resident #12's mouth to stop her from screaming. The LVN C also threatened to push Resident #12 into cold water if she did not stop screaming. The Administrator did not follow the abuse policy when she unfounded the abuse when the LVN admitted she had abused the resident. LVN C was suspended for part of her shift and returned to work the following day. Resident #13 was physically abused by Resident #12. Resident #12 slapped Resident #13 in the face. Resident #12 had a history of abusive behaviors. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were unable to carry out ADLS received necessary services to maintain personal hygiene were provided for 13 of 18 residents reviewed for ADLs (Resident #1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 14, 16, and # 18.) The facility failed to provide timely incontinent care for Resident #1, Resident #3, and Resident #15. The facility failed to provide showers for 26 residents on 9/18/23. The facility failed to provide routine showers for Resident #1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, and # 18. This failure could place dependent residents at risk for poor hygiene, skin infections and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient staff to provide nursing related ser ices to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, for 13 of 18 residents reviewed for sufficient staff (Resident #1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, and # 18.) The facility failed to have sufficient staff to provide timely incontinent care for Resident #1, Resident #3, and Resident #15. The facility failed to have sufficient staff to provide showers for 26 residents on 9/18/23. The facility failed to have sufficient staff to provide routine showers for Resident #'s 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, and 18. This failure placed dependent residents at risk for poor hygiene, not receiving care in a timely manner, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure the competency of a certified nurse aide for 6 of 13 CNA's reviewed (SNA D, I, J, L N, and O.) They failed to ensure the nurse aides were certified, and or trained in a state approved training program. They failed to provide evidence the nurse aide had received proficiency training and passed their test for SNA D and SNA J prior to 9/10/23 as required by the waiver program. They failed to ensure SNA I, L, N, and O were certified nurse aides prior to assuming full CNA duties without the oversite of another CNA. This failure placed residents at risk of not receiving proper ADL care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a resident with a diet that met his daily nutritional and special dietary needs for 1 of 5 residents reviewed for diet (Resident # 4.) The facility did not ensure Resident #4's physician ordered diet of no bread and no pasta was followed. This negative finding could cause residents discomfort and digestive issues. Findings Included: Record review a Resident #4 face sheet dated 9/20/23 indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were depression, Alzheimer's, disease, constipation, and muscle weakness. Record review of an admission MDS dated [DATE] indicated Resident #4 did not have any cognitive impairment. Resident #4 required supervision with eating with set up help only. [...]

Inspectors wroteBased on observation and interview the facility failed to have a Nurse Staff Information sheet posted. The facility staff were unable to determine how many staff were supposed to be in the building for one of one facility. This negative finding did not allow staff or visitor to determine the number of staff needed to provide care to the facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene were provided for 1 of 5 residents reviewed for ADLs (Resident # 2). The facility did not provide Resident #2 with her scheduled showers/baths. This failure could place dependent residents at risk for poor personal hygiene, skin infections and decreased quality of life. Findings Included: Record review of the face sheet for Resident #2 indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including cerebral palsy (condition marked by impaired muscle coordination and/or other disabilities, typically caused by damage to the brain before or at birth), type II diabetes, muscle weakness, depression, anxiety, and obesity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 1 of 3 residents reviewed for pressure injuries (Resident #1). The facility did not complete weekly skin assessments on Resident #1. The facility did not promptly identify and initiate treatment for the Stage II pressure injury to Resident #1's sacrum. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 5 residents (Resident #2) reviewed for resident rights. The facility did not ensure Resident #2 was assisted out of bed at her request on 8/27/23. This failure could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.