Gilman Healthcare Center

In the surveyor’s words

From the most serious findings on record at Gilman Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 14, 2026

  Failures at this level required more than one Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to ensure a resident who fell from a wheelchair while being transported by a staff member was assessed for potential head, cervical spine, or other injuries prior to being moved and failed to ensure the resident was safely transported in a wheelchair with required foot pedals for two (R2, R7) of ten residents reviewed for accident hazards and supervision on the sample list of 11. These failures resulted in R2 sustaining two acute C1 cervical spine fractures and left facial fractures. R2 expired at the hospital after the fall. R2's death certificate documents a contributing factor as Fall at Nursing Home and the manner of death as Accident. […]

• Immediate jeopardy, isolatedF686Sep 1, 2023

  Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to develop a care plan and interventions for a resident (R4) who is at high risk for developing pressure ulcers and has a history of pressure ulcers. The facility failed to implement pressure relieving interventions, routinely assess resident's skin, identify a pressure ulcer, assess a pressure ulcer upon identification, report a pressure ulcer to the wound nurse and physician, implement a treatment, and ensure open wounds were covered for one (R4) of five residents reviewed for pressure ulcers and repositioning in the sample list of five. […]

• Actual harm, isolatedF686Aug 20, 2026

  Based on observation, interview, and record review the facility failed to implement pressure relieving interventions, transcribe treatment orders, and complete skin assessments for two (R4, R32) of three residents reviewed for pressure ulcers in the sample list of 44 residents. These failures resulted in R4's stage one pressure ulcer deteriorating to an unstageable pressure ulcer and R32 developing a facility acquired unstageable pressure ulcer that deteriorated to a stage three. […]

• Actual harm, isolatedF689Aug 20, 2026

  Failures at this level required more than one deficient practice statement.A. Based on observation, interview, and record review the facility failed to provide supervision for one (R4) resident with a known history of taking food from other trays resulting in R4 choking requiring the Heimlich maneuver. R4 is one of four residents reviewed for accidents in the sample list of 44 residents.B. Based on observation, interview, and record review the facility failed to document elopement attempts, reassess for elopement risk, implement interventions and revise care planned interventions to prevent elopement for one (R49) of four residents reviewed for accidents in the sample list of 44 residents.C. […]

• Actual harm, isolatedF689Jan 4, 2025

  Based on interview and record review, the facility failed to adequately assess and supervise a cognitively impaired resident for the use of an electric assisted standing recliner for one (R1) of three residents reviewed for accidents on the sample list of five. This failure resulted in R1 falling and receiving a left subdural hematoma and a nondisplaced fracture of the left frontal bone. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 8, moderate cognitive impairment, needed substantial assistance with Activities of Daily Living (ADL), wheelchair bound and dependent on staff to and unable to ambulate. R1's Fall Risk Evaluation dated 11/16/24 documents R1 was at risk for falls. […]