Focused Care of Gilmer

In the surveyor’s words

From the most serious findings on record at Focused Care of Gilmer, in the surveyor’s own words.

• Immediate jeopardy, patternF600Apr 6, 2023

  Based on interview and record review the facility failed to ensure that residents were free from neglect 1 of 3 (Resident #1) residents reviewed for neglect. The facility failed to have an effective system in place for referrals resulting in Resident #1 not receiving a referral to the vascular specialist as ordered by his primary care physician and having an above the knee amputation to his right leg. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 4/04/23 at 3:00 p.m. While the IJ was removed on 4/06/23, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. […]

• Immediate jeopardy, patternF684Apr 6, 2023

  Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. 1. The Facility Failed to follow-up with the physician regarding referral ordered 3/02/23 to the vascular specialist in a timely manner resulting in Resident #1 not being seen by the vascular specialist and having an above the knee amputation of the right leg on 3/31/23. 2. […]

• Immediate jeopardy, isolatedF684Apr 8, 2026

  Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure RN A assessed Resident #1's vital signs and neurological status after his fall on 03/23/26. Vital signs were not checked until the next morning when the family requested the Resident to be sent to the emergency room. Resident #1 took Eliquis (anticoagulant medication). 2. The facility failed to obtain, review, and follow-up on Resident #1's hospital records after his return from the emergency room on [DATE]. […]

• Immediate jeopardy, isolatedF689Apr 8, 2026

  Based on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards in that: 1. On 03/23/26, the facility failed to ensure that Resident #1 did not lay on the floor for approximately 2 hours and 20 minutes after falling out of bed. 2. The facility failed to ensure that RN A, LVN B, and CNA C appropriately transferred Resident #1 back to bed post fall. 3. The facility failed to ensure that RN A and CNA C monitored Resident #1 every 2 hours. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 04/07/26 at 10:18AM. […]

• Immediate jeopardy, isolatedF580Nov 9, 2022

  Based on interview and record review the facility failed to immediately inform the physician when there was a significant change in the resident's physical and mental status for 1 of 6 residents whose records were reviewed for change in condition. (Resident #1) 1. The facility failed to notify the physician Resident #1 was not receiving her indefinitely prescribed antibiotic related to vertebral [CONDITION(S)]. 2. The facility failed to notify the physician Resident #1 did not receive her vertebral x-ray that was ordered related to her complaints of severe back pain. 3. […]