Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, accurate resident assessments, respiratory care, medication storage and labeling, and medical record accuracy at Gainesville Health and Rehabilitation.
Findings
The facility was found deficient in promoting dignified resident care during meals, ensuring accurate resident assessments, providing safe respiratory care, properly labeling and securing medications, and maintaining accurate medical records regarding advanced directives. All deficiencies were cited with minimal harm or potential for actual harm.
Deficiencies (5)
Failed to promote a dignified and homelike dining experience while assisting dependent residents with breakfast when staff stood over residents during the meal.
Failed to ensure each resident was provided with an assessment which accurately reflects the resident's status for respiratory care, skin conditions, and end stage renal disease care.
Failed to ensure respiratory care and services were provided consistent with professional standards of practice for oxygen therapy.
Failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and stored in locked compartments.
Failed to safeguard resident-identifiable information and/or maintain medical records on each resident that are accurate and complete, specifically regarding advanced directives.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 1
Medication carts observed: 5
Units observed: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in dignified dining assistance deficiency |
| Staff F | Licensed Practical Nurse (LPN), MDS Coordinator | Named in inaccurate resident assessment deficiency |
| Staff G | Licensed Practical Nurse (LPN), MDS Coordinator | Named in inaccurate resident assessment deficiency |
| Staff K | Licensed Practical Nurse (LPN) | Named in medication labeling and storage deficiency |
| Director of Nursing | Named in medication storage and advanced directive deficiencies | |
| Assistant Director of Nursing | Named in oxygen therapy and medication storage deficiencies |
Inspection Report
Routine
Deficiencies: 2
Date: Nov 19, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards for administering tube feedings and infection prevention and control practices, including the use of Enhanced Barrier Precautions for residents with feeding tubes and urinary catheters.
Findings
The facility failed to ensure proper professional practice in administering tube feedings for one resident and failed to prevent possible infection spread by not performing hand hygiene or using appropriate personal protective equipment (PPE) during care for two residents on Enhanced Barrier Precautions.
Deficiencies (2)
Failure to ensure standards of professional practice were followed for administering tube feedings with the use of a tube feeding pump for 1 of 5 residents.
Failure to prevent possible spread of infection by not performing hand hygiene or using appropriate PPE when performing care for 2 of 11 residents on Enhanced Barrier Precautions.
Report Facts
Residents affected: 1
Residents affected: 2
Date of survey completion: Nov 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant | Named in findings related to improper handling of feeding pump and failure to use PPE and hand hygiene |
| Staff C | Licensed Practical Nurse | Named in findings related to failure to use PPE and hand hygiene during resident care |
| Staff D | Certified Nursing Assistant | Named in findings related to failure to use PPE and hand hygiene during care of Resident #9 |
| Staff E | Occupational Therapist | Named in findings related to failure to use PPE and hand hygiene during transfer of Resident #9 |
| Director of Nursing | Director of Nursing | Provided interviews clarifying facility policies and staff expectations regarding PPE and hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 1, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify residents or their representatives in writing about the bed hold policy upon transfer to a hospital.
Complaint Details
The complaint investigation found that the facility did not provide written bed hold notices to residents or their representatives upon hospital transfer, affecting Residents #1, #2, and #3. The complaint was substantiated based on record reviews and staff interviews.
Findings
The facility failed to provide written bed hold notices to residents or their representatives for 3 of 3 residents reviewed who were transferred to hospitals. Interviews with the Administrator and Director of Nursing confirmed the absence of bed hold notification forms despite policy requirements.
Deficiencies (1)
Failure to notify residents or their representatives in writing about the bed hold policy upon transfer to hospital for 3 of 3 residents reviewed.
Report Facts
BIMS score: 15
BIMS score: 15
Hemoglobin level: 6.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding hospital transfers and bed hold policy | |
| Director of Nursing (DON) | Interviewed regarding notification practices and absence of bed hold forms |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Dec 22, 2023
Visit Reason
The inspection was conducted based on complaints and concerns related to abuse prevention training, accurate resident assessments, PASARR screenings, nutritional care, respiratory care, medication storage and labeling, medical record accuracy, infection control practices, and staff education on abuse and neglect.
Complaint Details
The complaint investigation was substantiated with findings of failure to provide abuse and neglect training to the Chef, failure to report abuse allegations timely, inaccurate resident assessments, failure to complete PASARR screenings, inadequate nutritional care, improper respiratory care, medication storage and labeling issues, incomplete medical records, and failure to perform hand hygiene during medication administration.
Findings
The facility was found deficient in multiple areas including failure to provide abuse and neglect training to the Chef, inaccurate resident assessments, failure to complete PASARR screenings for residents with serious mental disorders, inadequate nutritional interventions leading to weight loss, improper respiratory care equipment handling, expired and unlabeled medications on medication carts, incomplete and inaccurate medical record documentation, failure to perform hand hygiene during medication administration, and lack of abuse and neglect training for the Chef.
Deficiencies (9)
Failure to ensure policies and procedures were implemented for prevention of abuse, neglect, exploitation, and misappropriation of resident property related to training for 1 of 10 employees (the Chef) and timely reporting of allegations.
Failure to ensure resident assessments accurately reflected resident status for dialysis and restraints.
Failure to ensure residents reviewed for PASARR with newly evident or possible serious mental disorders were referred to appropriate state authority.
Failure to provide adequate nutritional interventions to maintain acceptable nutritional status for 1 resident.
Failure to provide safe and appropriate respiratory care consistent with professional standards for 1 resident.
Failure to ensure drugs and biologicals were stored and labeled in accordance with professional principles for 3 of 4 medication carts.
Failure to ensure resident records were complete and accurately documented for 2 of 4 residents reviewed for intravenous catheters.
Failure to ensure staff performed hand hygiene during medication administration to prevent infection transmission.
Failure to ensure the Chef completed training on abuse, neglect, and exploitation.
Report Facts
Weight loss percentage: 15.46
Weight loss percentage: 4.62
Medication carts with deficiencies: 3
Residents reviewed for PASARR: 6
Residents failed PASARR referral: 3
Residents reviewed for nutrition: 7
Residents reviewed for respiratory care: 2
Residents reviewed for IV catheter documentation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Confirmed Chef had no abuse training and had not attended in-services | |
| Staff A | Licensed Practical Nurse (LPN) | Notified Director of Nursing about resident altercation and called police |
| Staff B | Registered Nurse (RN) | Reported resident upset and in another resident's room during incident |
| Staff C | Certified Nursing Assistant | Observed serving inadequate food portions to Resident #19 |
| Staff D | Registered Nurse (RN) | Observed with expired and unlabeled medications on medication cart |
| Staff E | Licensed Practical Nurse (LPN) | Observed with unlabeled eye drops on medication cart |
| Staff F | Licensed Practical Nurse (LPN) | Observed with expired and unlabeled medications on medication cart |
| Staff G | Licensed Practical Nurse (LPN) | Observed failing to perform hand hygiene during medication administration |
| Director of Nursing | Director of Nursing | Provided multiple interviews confirming deficiencies and policies |
| Certified Dietary Manager | Certified Dietary Manager | Reported issues with meal preparation and tray card system |
| Registered Dietician | Registered Dietician | Confirmed weight loss alert was not triggered for Resident #19 |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 6, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding the appropriate use and care of feeding tubes in residents, specifically ensuring that feeding tubes are used only when medically necessary and that care is provided according to physician orders.
Findings
The facility failed to ensure appropriate treatment and services for enteral nutrition for 1 of 3 residents (Resident #3), including incorrect administration of water flush amounts via feeding tube not matching physician orders. Policies on medication administration via enteral tubes and appropriate use of feeding tubes were reviewed and found to be in place.
Deficiencies (1)
Failure to ensure appropriate treatment and services for enteral nutrition for Resident #3, including incorrect water flush amount via feeding tube not matching physician orders.
Report Facts
Feeding pump rate: 60
Water flush rate: 40
Water flush rate: 80
Hours feeding administered: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding feeding tube flush rate discrepancy for Resident #3 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff compliance with physician orders |
Inspection Report
Routine
Deficiencies: 11
Date: Jul 14, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, privacy, medication administration, infection control, therapy services, staffing, and other care standards at Gainesville Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were informed of their rights to formulate advance directives, lack of privacy for residents with indwelling catheters, unclean feeding equipment, failure to timely report abuse investigations, improper care of PICC lines, medication errors, unlabeled medications, failure to post nurse staffing data, failure to provide ordered therapy services, improper food labeling, and inadequate infection control practices including hand hygiene and water system monitoring.
Deficiencies (11)
Failed to ensure residents were informed and provided written information concerning their right to choose and to formulate an advance directive for 19 of 33 residents reviewed.
Failed to ensure personal privacy for residents with indwelling catheters for 5 of 8 residents with urinary catheters.
Failed to maintain a clean environment for 2 of 4 residents requiring tube feeding equipment.
Failed to timely report the results of all investigations of suspected abuse to proper authorities within 5 working days.
Failed to ensure residents received treatment and care in accordance with professional standards for peripherally inserted central catheters for 2 of 3 reviewed residents.
Failed to post nurse staffing information daily in a prominent place readily accessible to residents and visitors.
Medication error rate was 20.8%, failing to ensure medication error rates were not 5 percent or greater for 2 of 4 residents observed during medication pass.
Failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles and included expiration dates when applicable in 2 of 4 medication carts reviewed.
Failed to provide therapy services for 1 of 3 residents reviewed for therapy services.
Failed to store food items in accordance with professional standards for food service safety in the facility's nourishment room.
Failed to maintain infection control practice standards for performing hand hygiene during medication administration in 6 out of 8 observations and failed to conduct monthly water supply monitoring.
Report Facts
Residents reviewed: 33
Residents affected: 19
Residents with urinary catheters: 8
Residents affected: 5
Residents requiring tube feeding equipment: 4
Residents affected: 2
Medication error rate: 20.8
Residents observed: 4
Residents affected: 2
Medication carts reviewed: 4
Medication carts with labeling issues: 2
Residents reviewed for therapy: 3
Residents affected: 1
Residents affected: 1
Medication administration observations: 8
Observations with hand hygiene failure: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Social Services Assistant | Confirmed residents' files lacked documentation of advance directives |
| Staff Q | Certified Nursing Assistant | Stated no privacy bags were available for catheter bags |
| Staff K | Licensed Practical Nurse | Commented on catheter bags not being covered with privacy bags |
| Administrator | Acknowledged lack of catheter privacy bags and failure to post nurse staffing data | |
| Staff A | Licensed Practical Nurse | Performed PICC line dressing change and medication administration with procedural errors |
| Staff C | Licensed Practical Nurse | Observed administering medications without proper hand hygiene |
| Staff D | Registered Nurse | Observed medication administration with omissions |
| Staff F | Central Supply Clerk | Responsible for ordering medication supplies and reported medication shortages |
| Staff I | Staff Coordinator | Reported stopping federal staffing sheet posting |
| Staff J | Business Office Manager | Commented on staffing posting responsibilities |
| Therapy Director | Acknowledged failure to provide therapy services to Resident #17 | |
| Certified Dietary Manager | Verified unlabeled food items in nourishment room | |
| Director of Nursing | Provided comments on medication labeling and cleaning responsibilities |
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