Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gilmer Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with early-onset Alzheimer’s disease, severe cognitive impairment, and dependence on staff for bathing did not have her shower preferences documented in her care plan and was scheduled for nighttime showers based on a standardized hall-based bathing schedule. Her family repeatedly requested that showers be provided during the day, but staff, including the DON and ADON, stated they would only provide day-shift showers when time allowed and otherwise continued with night-shift bathing. As a result, the resident frequently received late-night bed baths instead of showers, and her hair was observed to be greasy, limp, and clumped together, indicating that her expressed preference for daytime showers was not honored.
A resident with severe cognitive impairment and dependence on staff for bathing had repeated missed showers and went over two weeks without having her hair washed because showers were scheduled on the night shift, when she was already in bed and instead received bed baths. The resident’s family member repeatedly asked the ADON and DON to move the shower time to days to match the resident’s sleep schedule, but these requests were not documented in the grievance log, and the care plan did not reflect the resident’s shower preferences. The DON acknowledged knowing about the requests but did not treat them as grievances due to the standard hall-based bathing schedule, and the ADON admitted she was unsure of the grievance process and did not record the complaints, contrary to the facility’s grievance policy requiring prompt resolution of grievances.
Surveyors found a treatment cart left unlocked and unattended on a resident hall, with a wound cleanser bottle on top and prescription triamcinolone cream accessible in the top drawer. Staff and residents were present nearby, and no staff intervened when the cart was opened by a surveyor. The Treatment Nurse later reported she had stepped away to assist an aide and had not locked the cart or stored the wound cleanser, despite facility policy requiring medications and potentially harmful substances to be securely stored and accessible only to authorized personnel. The Administrator and DON both stated their expectation that treatment carts remain locked or under direct supervision at all times.
A resident with dementia, recurrent UTIs, and prophylactic antibiotic therapy developed increased agitation, confusion, and exit-seeking behaviors, prompting an order for UA with C&S. The UA was sent to the physician, but when the C&S later returned abnormal and positive for E. coli, the result was not entered on the 24-hour report or promptly communicated to the physician on the day it was received. Nursing leadership and corporate compliance staff reported that nurses were responsible for checking labs each shift and using the 24-hour report and clinical meetings to ensure follow-up, but this process was not followed, resulting in delayed physician notification of the abnormal lab result.
A resident with multiple chronic conditions, moderate cognitive impairment, and dependence on staff for toileting received incontinent care from two CNAs who removed a soiled brief but did not change their soiled gloves or perform hand hygiene before applying barrier cream. Both CNAs later stated they knew they were required to remove soiled gloves and perform hand hygiene during peri care but failed to do so. The DON and Administrator confirmed that staff are expected to follow facility policy requiring glove changes and hand hygiene during perineal care to prevent infections, and records showed both CNAs had previously been deemed competent in perineal/incontinent care.
The facility did not have an RN on duty for 8 consecutive hours on a holiday, as required. The DON was not present, and no other RN was assigned. The Administrator acknowledged the oversight and the absence of a policy for RN coverage.
A facility failed to coordinate PASRR assessments by not including a hospice representative in IDT meetings for a resident needing specialized PT and OT services. This oversight led to the denial of PT services and potential delays in OT services due to incomplete information submitted to the PASRR Unit. The resident, with a history of seizures and intellectual disabilities, was affected by this deficiency.
The facility failed to develop comprehensive care plans for three residents with PASRR positive status, risking missed services. A resident with schizoaffective disorder, another with cerebral palsy and diabetes, and a third with anxiety had care plans that did not address their PASRR status. Interviews revealed the MDS nurse was responsible for this oversight, which was acknowledged by facility staff.
A facility failed to inform a resident's family about changes in Medicare coverage by not providing a SNF ABN when skilled services were discontinued. The resident, who had dementia and other health issues, continued on Medicaid services without the family being notified of the change. Staff interviews revealed a lack of awareness and training regarding the responsibility for issuing SNF ABN letters.
A facility failed to include a resident's depression diagnosis and prescribed antidepressant medication in the baseline care plan upon admission. The resident, an elderly male, was admitted with a diagnosis of depression and a physician's order for Amitriptyline. Interviews with the DON and Administrator highlighted that the care plan should have been informed by the resident's transfer papers, and its absence could lead to inadequate monitoring of the resident's condition.
A facility failed to remove expired medications from a medication cart, affecting a resident with dementia and anxiety. The resident's ABH gel syringes had expired, but due to a misunderstanding of expiration dates on labels, they were not removed. Nurses were responsible for removing expired medications, but confusion arose from labeling practices. Despite the oversight, the expired medication was not administered, though it could have been less effective.
The facility failed to maintain the gas stove in the kitchen in safe operating condition. One of the burners did not light using the pilot light and could not be lit with a lighter. The maintenance supervisor acknowledged the need for cleaning the pilot light and later confirmed that it was cleaned. The Administrator noted the absence of a specific equipment maintenance policy but expected the stove to function properly.
A resident with severe cognitive impairment fell and was improperly transferred back to bed by CNAs without a nurse's assessment, leading to a delayed diagnosis of a femur fracture. The resident later required increased pain management and adjustments to her care plan. The facility's staff failed to follow proper procedures, resulting in a breakdown of communication and protocol adherence.
Failure to Honor Resident Choice for Daytime Showers
Penalty
Summary
The facility failed to honor a resident’s right to make choices about significant aspects of her daily life, specifically her bathing schedule. A female resident with early-onset Alzheimer’s disease, severe cognitive impairment (BIMS score of 3), muscle weakness, gait and mobility abnormalities, lack of coordination, and hypertension was dependent on staff for showering and bathing. Her comprehensive care plan identified a self-care deficit and need for staff assistance with showering but did not document her shower preferences. Facility shower assignment records showed she was scheduled for showers on the 6 p.m.–6 a.m. shift three days per week, and during the review period she received bed baths late at night between approximately 10:18 p.m. and 11:39 p.m. instead of showers. The resident’s family member reported that over the last month the resident had missed several showers because the aide arrived so late in the evening that the resident was already ready to stay in bed, resulting in bed baths being provided instead of showers. The family member stated the resident’s hair had not been washed in over two weeks due to receiving bed baths rather than showers. The family member also reported that they had requested multiple times that the resident’s scheduled shower time be moved to the day shift, and that the ADON and DON responded they would try to provide day-shift showers if time allowed, otherwise the resident would continue to receive showers in the evening. Observation of the resident showed her hair was greasy, limp, and clumped together. Staff interviews confirmed awareness of the family’s request and the facility’s reliance on a standardized bathing schedule based on room location and hall assignment. CNA A stated that the resident’s family wanted the resident to be first on the 6 p.m. shift, but due to the shower schedule, the resident’s end of the hall was typically reached around 11 p.m., and that although residents should receive showers at their requested times, not everyone could have a day-shift shower. The DON acknowledged knowing of the family’s request for day-shift showers but stated the facility followed a standard bath schedule by hall and did not offer to move the resident to a different hall to accommodate the request. The ADON similarly stated that the facility used a standardized bathing schedule based on room location and that, due to this, the resident was showered on the night shift, with some showers provided during the day only when day-shift staff were able. The Administrator stated that if a family requested a day-shift shower, it should be person-centered and scheduled during the day, and that honoring residents’ choices was important, but she was not aware of this specific request.
Failure to Recognize and Address Repeated Shower-Schedule Complaints as Grievances
Penalty
Summary
The deficiency involves the facility’s failure to recognize and process repeated complaints about a resident’s shower schedule as formal grievances and to make prompt efforts to resolve them. A female resident with early-onset Alzheimer’s disease, severe cognitive impairment (BIMS score of 3), muscle weakness, gait and mobility abnormalities, lack of coordination, and hypertension was dependent on staff for showering and bathing. Her comprehensive care plan identified a self-care deficit and need for staff assistance with showering but did not document her shower preferences. The facility maintained a standard bathing schedule based on hall location, which placed this resident’s showers on the night shift. Over the course of about a month, the resident’s family member reported that the resident missed several showers because the aide arrived late in the evening when the resident was already ready to stay in bed, resulting in bed baths instead of showers. The family member stated the resident’s hair had not been washed in over two weeks due to receiving bed baths rather than showers. On observation, the resident’s hair appeared greasy, limp, and clumped together. The family member reported having requested multiple times that the resident’s scheduled shower time be moved to the day shift to accommodate her sleep schedule and stated these requests were made specifically to the ADON and discussed with the DON, who responded that they would try to provide day-shift showers if time allowed, otherwise the resident would continue to receive showers in the evening. Despite these repeated requests, review of the grievance logs showed no entry for a grievance from the resident’s family member. The DON acknowledged awareness of the family member’s request and stated the ADON and other staff had brought the matter to her attention on different occasions, but she did not consider it a grievance because of the facility’s standard bathing schedule and did not offer a room move to another hall to accommodate day-shift showers. The ADON confirmed the family member had requested day-shift showers more than once, stated she was unsure of the facility’s grievance process, and admitted she did not document the requests for follow-up, instead only discussing them in morning meetings. The Administrator, who was responsible for the grievance log and follow-up, indicated that if these requests had been documented as a grievance, she would have been aware and able to address the issue. The facility’s written grievance policy required that residents be allowed to voice grievances without reprisal and that the facility make prompt efforts to resolve grievances, but the policy was not followed in this case, as the family’s repeated complaints were not entered or processed as grievances.
Unlocked Treatment Cart and Improper Storage of Wound Cleanser
Penalty
Summary
Surveyors identified a deficiency related to medication storage and security involving a treatment cart on Hall A. During an observation at 10:46 a.m., the treatment cart was found unlocked and unattended, with a wound cleanser bottle sitting on top of the cart. The cart could be opened by the surveyor, and prescription triamcinolone cream tubes were found in the top drawer. Residents and staff were observed in the vicinity of the unlocked cart, and no staff noticed or intervened when the surveyor opened it. The facility’s written policy on medication storage stated that medications and biologicals are to be stored safely, securely, and properly, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications, and that potentially harmful substances must be clearly identified and stored in a locked area separate from medications. In interviews, the Treatment Nurse stated she usually locked the treatment cart because it contained items and some medications, including wound cleanser and creams, that could be potentially dangerous if ingested by a resident. She reported that she had stepped into the shower room to assist an aide with a resident and did not take the time to put the wound cleanser away or lock the treatment cart before leaving it unattended. The Administrator stated she expected the Treatment Nurse to keep the treatment cart locked at all times to prevent accidents such as a resident drinking or spraying a harmful substance into their eyes. The DON stated she expected the treatment cart to be either under the direct supervision of the Treatment Nurse or locked at all times and reported that she conducted daily walks through the facility to check that medication and treatment carts remained locked.
Failure to Promptly Communicate Abnormal Urine Culture Results to Physician
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify and follow up with the ordering physician regarding abnormal urine culture and sensitivity results for one resident. The resident was an elderly female with cerebrovascular disease, candidiasis, muscle weakness, gait abnormalities, and dementia, with a severely impaired BIMS score and care plan indicating dependence for toileting and a self-care deficit. Her care plan also documented prophylactic antibiotic therapy for recurrent UTIs, but without listed interventions. On 12/24, a progress note documented increased agitation and exit-seeking behaviors, and the physician ordered a urinalysis with culture and sensitivity. The specimen was collected on 12/25 using sterile technique. On 12/27, progress notes showed that urinalysis results were received and sent to the physician, while the culture and sensitivity were still pending. That same day, the resident triggered alarms attempting to exit the facility and was admitted to the secured unit, with the ADON receiving her medications and urinalysis results. On 12/28, documentation indicated increased confusion, continued elopement attempts, and feces on the resident’s hands and bedding. On 12/29 at 1:32 p.m., the urine culture and sensitivity results were reported as abnormal and positive for E. coli. However, the 24-hour report for that date did not show that the lab results were faxed to the physician or that follow-up was required, and the resident’s progress notes for that date did not include the culture and sensitivity results. On 12/30, a progress note documented that the physician was notified of the urine culture and sensitivity results that had been received the previous day, with instructions to follow up with the resident’s urologist and no new orders at that time. The facility documented multiple messages left with the on-call agent and a fax of the lab results to the urologist. Additional notes that day indicated the resident continued on Keflex 250 mg daily as UTI prophylaxis and that a family member requested transfer to the hospital for further evaluation. Interviews with the family member, ADON, Regional Corporate Compliance, and Administrator confirmed that the lab results were not entered on the 24-hour report on the day they were received, that all nurses were responsible for lab follow-up, and that failure to document and communicate labs through the established processes could result in missed follow-up. The facility’s policy stated that when test results are reported, a nurse must review them and, if unable to complete the reporting and documentation process, another nurse should coordinate the procedure, which did not occur as required in this case.
Failure to Perform Hand Hygiene and Glove Change During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during incontinent care for one resident. The resident was an older female with diagnoses including congestive heart failure, gait and mobility abnormalities, chronic pulmonary edema, Type 2 diabetes mellitus, muscle weakness, and lack of coordination. A comprehensive MDS showed she had moderately impaired cognition with a BIMS score of 10, was dependent on staff for toileting, and required maximum assistance for showering and bathing. Her care plan documented a self-care deficit and the need for staff assistance with toileting. On the observed date and time, two CNAs entered the resident’s room to provide incontinent care, washed their hands, and applied gloves. During the care, both CNAs removed the resident’s soiled brief but did not change their soiled gloves or perform hand hygiene before applying barrier cream. In subsequent interviews, both CNAs acknowledged they were supposed to remove soiled gloves and perform hand hygiene between steps of perineal care and stated they failed to do so because they forgot or were nervous. The DON and Administrator both confirmed that facility expectations and policy required hand hygiene between glove changes and changing soiled gloves prior to applying barrier cream, and that these practices were important to prevent urinary tract infections, sepsis, and the spread of disease. Facility policy on perineal care required doffing and discarding visibly soiled gloves and performing hand hygiene before and after glove use.
Failure to Ensure RN Coverage on a Holiday
Penalty
Summary
The facility failed to ensure there was a registered nurse (RN) on duty for 8 consecutive hours on Thanksgiving Day, 11/28/24. This deficiency was identified through interviews and record reviews. The RN time sheets confirmed the absence of an RN on that day. During interviews, the Director of Nursing (DON) admitted she did not work on Thanksgiving Day and was unsure if any other RN was assigned to work. The Administrator acknowledged the lack of RN coverage and accepted responsibility for ensuring RN coverage. It was also noted that the facility did not have a policy regarding RN coverage, although they claimed to follow regulations.
Failure to Coordinate PASRR Assessments with Hospice Representative
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program effectively, resulting in a deficiency for one of the six residents reviewed. Specifically, the facility did not include the hospice representative in the Interdisciplinary Team (IDT) meetings for a resident with intellectual and developmental disabilities, which were necessary for requesting specialized physical therapy (PT) and occupational therapy (OT) services. The absence of the hospice representative in these meetings led to a lack of required information being submitted to the PASRR Unit, resulting in the denial of PT services and potential delays in OT services. The resident in question was a female with a history of seizures and intellectual disabilities, who had been marked as needing specialized services under the PASRR program. Despite requests from the PASRR Unit for additional information to authorize these services, the facility failed to ensure the hospice representative's participation in the IDT meetings, as required. This oversight was acknowledged by the facility's staff, including the MDS Nurse and the Director of Rehabilitation (DOR), who noted the scheduling issues and the potential for service delays or non-payment due to the incomplete meetings.
Failure to Address PASRR Positive Status in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents with PASRR positive status, which is required to address their medical, nursing, and mental and psychosocial needs. Resident #11, a female with schizoaffective disorder and bipolar type, was admitted with a PASRR positive status for mental illness and intellectual disability. Despite being on medications like Abilify and Olanzapine for her condition, her care plan did not reflect her PASRR positive status, which could lead to missed services. Resident #28, a female with cerebral palsy and diabetes, was also identified as PASRR positive. However, her care plan failed to address her PASRR status, potentially leading to a lack of necessary services. Similarly, Resident #34, a female with anxiety, had no care plan addressing her PASRR positive status, despite having a prescription for Buspirone to manage her condition. Interviews with facility staff, including the MDS nurse, DON, ADON, and the Administrator, revealed that the responsibility for care planning PASRR positive status was assigned to the MDS nurse. However, it was acknowledged that the PASRR positive status was overlooked in the care plans of these residents. The facility's policy mandates the development of comprehensive care plans that include measurable objectives and timeframes, but this was not adhered to, resulting in potential missed services for the residents.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to ensure that residents were informed of services available and charges for those services, including those not covered under Medicare/Medicaid. Specifically, Resident #54 was not provided with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when discharged from skilled services, which is a document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services. This oversight was identified during a review of Resident #54's records, which showed that the resident was admitted with Medicare Part A for skilled nursing care, with coverage ending on 08/31/24, and continued on Medicaid services thereafter. However, there was no record of the SNF ABN being given to the resident's family or responsible party. Interviews and observations revealed that the MDS nurse was unaware of her responsibility for issuing the SNF ABN letters and was scheduled to receive training on the same day the deficiency was noted. Additionally, the facility's Administrator expressed uncertainty about the requirement to complete the SNF ABN form and planned to seek guidance from corporate for training. This lack of awareness and training among staff contributed to the failure to inform Resident #54's family or responsible party about the change in coverage, potentially placing residents at risk of being unaware of changes to the services provided.
Failure to Include Depression Diagnosis in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed for a newly admitted resident, specifically omitting the resident's diagnosis of depression and the prescribed antidepressant medication, Amitriptyline. The resident, an elderly male, was admitted with a diagnosis of depression and had a physician's order for Amitriptyline 25mg daily. However, the baseline care plan did not address these critical aspects of his care, which are essential for providing effective and person-centered care. Interviews with the Director of Nursing (DON) and the Administrator revealed that the responsibility for completing care plans lies with the nursing staff, and the baseline care plan should be informed by the resident's transfer papers. The DON acknowledged that the absence of a care plan addressing the resident's depression and medication could lead to inadequate monitoring of his condition. The facility's policy on baseline care plans emphasizes the importance of reflecting the resident's immediate needs and incorporating information from admission orders and discussions with the resident or their representative.
Expired Medications Not Removed from Medication Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not removing expired medications from a medication cart, specifically affecting Resident #4. The resident, a female with dementia and anxiety, was prescribed ABH gel, a compounded medication for anxiety and restlessness. The medication cart contained syringes of ABH gel with expiration dates that had passed, yet they were not removed from use. The oversight was discovered during a survey when it was noted that the syringes had expired 68 and 35 days prior, respectively. The issue arose from a misunderstanding of the expiration dates on the medication labels. The nurses, including LVN C, were checking the wrong expiration date on the medication labels, leading to the expired medications remaining on the cart. The facility's pharmacy had a practice of marking out the original expiration date when medications were compounded, but the hospice pharmacy that provided these medications did not follow this practice, contributing to the confusion. Despite the presence of expired medications, it was noted that LVN C had not administered the expired medication. Interviews with various staff members, including the DON, ADON, and the Pharmacy Consultant, revealed that the responsibility for removing expired medications lay with the nurses, with additional checks by the pharmacy consultant and nurse managers. However, due to the discrepancy in labeling, the expired medications were overlooked. The staff acknowledged that administering expired medication could result in reduced effectiveness, although it was not considered harmful. The facility's policy required expired medications to be submitted to the DON for destruction, but this procedure was not followed in this instance.
Gas Stove Maintenance Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the gas stove. During an observation, it was noted that one of the six burners on the stove did not light using the pilot light and could not be lit with a long lighter. This issue was reported to the maintenance supervisor, who acknowledged that the pilot light required cleaning at times. The maintenance supervisor later confirmed that he had cleaned the pilot light and removed a fan in the kitchen. The Administrator stated that there was no specific policy regarding equipment maintenance, but the expectation was for the stove to function properly.
Improper Handling of Resident Post-Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice after a fall. The resident, who had severe cognitive impairment and was on hospice care due to Alzheimer's disease, fell while attempting to walk from a sitting position. Despite the fall being witnessed by CNAs, the resident was improperly transferred back to her bed without being assessed by a nurse first. This action was contrary to the facility's protocol, which requires a nurse to assess a resident before any movement after a fall. The incident report indicated that the resident was initially assessed with no visible injuries, but later complained of pain in her right hip/thigh area. An x-ray confirmed an acute fracture of the proximal femur. Interviews with staff revealed that the CNAs moved the resident without notifying the nurse immediately, and the nurse was not informed of the fall until approximately an hour later. The CNAs admitted to transferring the resident improperly, and the nurse on duty did not perform a thorough assessment upon being informed of the fall. The facility's failure to follow proper procedures for assessing and handling a resident after a fall led to a delay in identifying a serious injury. The resident's condition required increased pain management and adjustments to her care plan, including the use of a low air loss mattress and a foley catheter for comfort. The incident highlights a breakdown in communication and adherence to protocol among the facility's staff, which could have placed the resident at risk of further harm.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gilmer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care Of Gilmer | 0.9 mi | — | 19 | 2 |
| Legend Oaks Healthcare And Rehabilitation Center - | 12.6 mi | — | 13 | 0 |
| Truman W Smith Children's Care Center | 13.2 mi | — | 5 | 0 |
| Pine Tree Lodge Nursing Center | 15.9 mi | — | 17 | 2 |
| Avir At Pittsburg | 17.8 mi | — | 1 | 0 |
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