Gainesville Nursing

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF602Mar 12, 2026

  Based on observation, interview and record review, the facility failed to protect all residents from misappropriation of resident property when staff could not account for 19 missing narcotics tablets for 10 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10). The facility census was 43. Review of the facility policy titled Abuse, Prevention and Prohibition Policy, revised 10/22, showed the following information:-Should a specific employee be suspected of or have allegations made of misappropriation, the facility will follow the investigation protocol set forth in this policy;-The facility will educate staff on the policy and procedure for prevention of misappropriation of resident property and of… […]

• No harm, potential for more than minimal, patternF804Sep 12, 2024

  Based on observation and interview, the facility failed to ensure food prepared by the facility was palatable when residents complained the food was served cold at times, the food lacked flavor/seasoning, and the meat was tough at times. 1. Observations and interview on 09/11/24, at 1:07 P.M., showed the following: -The Dietary Manager (DM) confirmed testing the food on the last (test) tray on the cart. Prior to leaving the kitchen the temperature of the cheesy rice casserole was 120 degrees Fahrenheit (F); pork chop was 125 degrees F; and the broccoli was 115 degrees F. -When the tray was presented after the last tray was delivered, the casserole was 110 degrees F, the pork chop was 95 degrees F, and the broccoli was 90 degrees F. […]

• No harm, potential for more than minimal, patternF700Nov 17, 2022

  Based on observation, interview, and record review, the facility failed to complete a risk/benefit review and document alternatives attempted prior to bed rail use for five residents (Residents #8, #12, #27, #31, and #199); failed to obtain informed consent prior to the use side rails for one resident (Resident #31); failed to address the use bed rails in residents' care plans for four residents (Residents #8, #12, #31, and #199); and failed to obtain physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF602Jan 6, 2026

  Based on interview and record review, the facility failed to protect all resident from misappropriation of property when one facility staff member (Environmental Services Employee A) used one resident's (Resident #1) debit card without consent. The facility census was 46.On 12/26/25, the Social Services Worker became aware of the misappropriation. The facility immediately began their investigation, including multiple interviews of other residents and staff. The facility began education on abuse, neglect, and misappropriation of resident's property. The facility removed Environmental Services Employee A from the facility. The facility reviewed all other resident's accounts with a debit card, as well as educated the residents on the process for debit card transactions. […]

• No harm, potential for more than minimal, isolatedF609Nov 14, 2024

  1. Please refer to Event ID B3N912, exit date 11/14/24. MO00243241