Gilmer Nursing & Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Nov 2, 2023

  45810 Based on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 13 (Residents #7, #31, #208, #30, #39, #45, #32, #44, #28, #15, #16 , #34, #25 ) of 15 residents and 9 employees ( LVN B, MDS nurse, Dietary staff V, CNA D, Housekeeping Supervisor, Housekeeper Y, Housekeeper EE, CNA N, and CNA H ) out of 135 employees in the facility, 1 (RN DD) of 1 contract employees and 1 (clean cart) of 3 linen carts reviewed for infection control practices and transmission-based precautions. 1. […]

• Immediate jeopardy, patternF600Oct 4, 2023

  Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, and neglect for 3 of 18 residents reviewed for abuse and neglect (Resident #12, Resident #13, and Resident #14) in that: Resident #12 was abused when LVN C put her hand over Resident #12's mouth to stop her from screaming. LVN C also threatened to push Resident #12 into cold water if she did not stop screaming. Resident #13 was physically abused by Resident #12. Resident #12 slapped Resident #13 in the face. Resident #12 had a history of abusive behaviors. Resident #12 disliked Black people and targeted two Black residents on the secure unit, Resident #13, and Resident #14. An Immediate Jeopardy (IJ) situation was identified on 10/3/23 at 6:00 p.m. […]

• Immediate jeopardy, patternF607Oct 4, 2023

  Based on observation, interview, and record review the facility failed to implement written polices and procedures to prohibit abuse by ensuring residents had the right to be free from abuse, and neglect for 3 of 18 residents reviewed for abuse and neglect (Resident #12, Resident #13, and Resident #14). Resident #12 was abused when LVN C put her hand over Resident #12's mouth to stop her from screaming. The LVN C also threatened to push Resident #12 into cold water if she did not stop screaming. The Administrator did not follow the abuse policy when she unfounded the abuse when the LVN admitted she had abused the resident. LVN C was suspended for part of her shift and returned to work the following day. Resident #13 was physically abused by Resident #12. […]

• Immediate jeopardy, patternF600Apr 23, 2022

  Based on observation, interview, and record review the facility failed to ensure residents were free from sexual abuse for 2 of 4 residents (Resident # 2, Resident #3 Resident #5, Resident #6) reviewed for abuse from Resident #1 The facility failed to protect cognitively impaired female residents from unwanted sexual behaviors from Resident #1. The facility failed follow their Abuse Policy in providing an environment free from abuse. The facility failed to develop or update a care plan that provided actual interventions for Resident #1's aggressive sexual behaviors. […]

• Immediate jeopardy, isolatedF684Aug 1, 2024

  Based on interviews and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 8 (Resident #1) residents reviewed for quality of care. The facility did not ensure Resident #1 was assessed by a nurse after a fall. Resident #1 was improperly transferred to her bed by CNA G and CNA H without first being assessed by the nurse, LVN E. The noncompliance was identified as PNC. The IJ began on 1/30/24 and ended on 2/2/24. The facility had corrected the noncompliance before the investigation began. These failures could place residents at risk of serious harm, and not receiving the necessary interventions to reach their highest practicable physical, mental, and psychosocial well-being. […]