Gainesville Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Gainesville Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF578Aug 20, 2026

  Based on record review and interview the facility failed to review advance directives options with 18 residents, Resident #2, #6, #7, #10, #11, #12, #46, #59, #67, #75, #76, #85, #86, #89, #92, #95, #100, and #109 reviewed for advance directives. Findings include: 1) Review of Resident #10's medical record documented an admission date of 2/6/2025. The medical record did not contain documentation the facility had reviewed advance directive options with Resident #10. Review of Resident #10's Advance Directives/Informed Consent form showed the form was not completed, dated or signed by Resident #10 or facility staff. 2) Review of Resident #11's medical record documented an admission date of 9/4/2021. […]

• No harm, potential for more than minimal, widespreadF851Aug 20, 2026

  Based on interview and record review, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data in a uniform format.Findings include:Review of the CASPER (Certification and Survey Provider Enhanced Reports - a system and database used by healthcare facilities) report for quarter one (1/01/2026 through 3/31/2026) revealed that the facility triggered for 24 dates with zero registered nurse (RN) hours. During an interview on 8/18/2026 at approximately 9:00 AM the DON (Director of Nursing) stated that there had not been any days when an RN (registered nurse) was not in the facility. […]

• No harm, potential for more than minimal, widespreadF725Jun 30, 2026

  Based on interview, observation, and record review, the facility failed to have sufficient nursing staff to assure residents maintained the highest practicable physical, mental, and psychosocial well-being in 3 of 3 resident units reviewed for sufficient staffing.Findings include:During an interview on 6/28/2026 at 6:40 AM, Staff J, Registered Nurse (RN), stated, I work night shift 7p-7a [7 PM to 7 AM]. I had 24 residents assigned to me last night. I am not in charge, but I am an RN. We do not have a supervisor or a charge nurse right now.During an interview on 6/28/2026 at 6:56 AM, Staff A, Certified Nursing Assistant (CNA), stated, I had 36 residents last night. There have been times I have had 37. I am not able to give the best care when I have this many residents. I am tired. […]

• No harm, potential for more than minimal, widespreadF867Jun 30, 2026

  Based on interview and record review, the facility failed to develop and implement a performance improvement plan upon identification of concerns related to staffing. Cross reference to F725:Findings include:Review of the facility's Quality Assurance and Performance Improvement (QAPI) agenda dated 6/10/2026 at 11:00 AM read, Updates of all outstanding items from last QAPI Meeting. Approval-Administrator. Review of survey citations/POC [plan of correction]. Current PIPS [performance improvement plans]. Kitchens PIPS. Staffing concerns. New issues/New opportunities. Closing.During an interview on 6/29/2026 at 12:03 PM, the Director of Nursing stated, Staffing has been discussed in QAPI [meeting], but we have no current PIPS for staffing. […]

• No harm, potential for more than minimal, widespreadF925Jun 30, 2026

  Based on observation, interview and record review, the facility failed to maintain an effective pest control program in 3 of 3 units reviewed.Findings include:During an interview on 6/28/2026 at 7:18 AM, Staff C, Certified Nursing Assistant (CNA), stated, I have seen a few roaches and gnats, we usually just kill them.During an observation on 6/28/2026 at 8:10 AM, there were three black flying insects in the main dining room (Photographic evidence obtained).During an interview on 6/28/2026 at 9:05 AM, Resident #6 stated, I have seen a lot of gnats and roaches everywhere. I have seen flies in my room and in the hallway. I told the staff about it. […]