Community Health Care of Gore

In the surveyor’s words

From the most serious findings on record at Community Health Care of Gore, in the surveyor’s own words.

• Immediate jeopardy, isolatedF607Mar 17, 2025

  On 03/06/25 at 5:40 p.m., an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to implement their abuse policy and procedure by not: a. consulting with the attending physician to identify treatable conditions such as acute psychosis; b. making any changes to care plan approaches to any and all involved individuals; c. documenting in the residents clinical record all attempted interventions and their effectiveness; and d. consulting psychiatric services for asssistance in assessing the resident, identifying causes, and developing a care plan for interventions and management necessary or as may be recommended by the attending physician or interdisciplinary team after a allegation of sexual abuse. […]

• Immediate jeopardy, isolatedF689Mar 17, 2025

  On 03/05/25, an immediate Jeopardy was determined to exist related to the facility's failure to implement fall interventions for Resident #3 who had severe cognitive impairment and was a high fall risk. A quarterly MDS assessment, dated 10/11/24, showed Resident #3 had one non injury fall and two or more falls with injury. Resident #3's Morse Fall Scale assessment, dated 09/24/24, showed Resident #3 was a high fall risk. On 11/03/24, Resident #3 fell from the bed with no injury. Resident #3's Morse Fall Scale assessment, dated 12/03/24, showed Resident #3 was a high fall risk. […]

• Actual harm, isolatedF600Mar 17, 2025

  Based on observation, record review, and interview, the facility failed to prevent abuse for 1 (#20) of 3 sampled residents reviewed for abuse. This deficient practice resulted in harm to Resident #20 who experienced psychosocial harm as a result of the abuse. The administrator identified 44 residents resided in the facility. Findings: 1. On 03/03/25 at 12:16 p.m., Resident #20 was observed crying and visibly traumatized while conveying the incident which occurred on 02/23/25. A facility policy titled Identifying Types of Abuse, revised 09/2022, read in part, the following situations are recognized as those that are likely to cause psychosocial Harm, which may take months or years to manifest and have long-term effects on the resident and [their]relationship with others: a. […]

• Actual harm, isolatedF657Mar 17, 2025

  Based on observation, record review, and interview, the facility failed to ensure: a. care plans were updated/revised for 1 (#3) of 16 sampled residents reviewed for updated/revised care plans; and b. the participation of the resident/resident's representative and the interdisciplinary team in the revision of the care plan for 1 (#12) of 16 sampled residents whose care plan were reviewed for participation of a resident/resident's representative and the interdisciplinary team in the revision of the care plan . This deficient practice resulted in a harm to Resident #3 after the resident experienced a fall with injury. […]

• Actual harm, isolatedF699Mar 17, 2025

  Based on observation, record review, and interview, the facility failed to provide trauma informed care after an incident of sexual abuse for 1 (#20) of 5 sampled residents reviewed for trauma informed care which resulted in a harm to Resident #20. The ADON identified 44 residents resided in the facility and 22 residents received mental health medications in the facility. Findings: On 03/03/25 at 12:16 p.m., Resident #20 was observed crying and visibly traumatized while conveying the incident which occurred on 02/23/25. […]