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Gilbert Veterans Home: Abuse Protection Failure - TN
CLARKSVILLE, TN - Federal health inspectors cited the Brigadier General Wendell H....
Latest reports, citations, and penalties from CMS data
CLARKSVILLE, TN - Federal health inspectors cited the Brigadier General Wendell H....
Infection prevention programs in nursing homes are designed to protect some of the most medically vulnerable individuals in the healthcare system....
The facility has since submitted a plan of correction....
Specifically, the facility failed to provide required documentation or notification related to **resident needs, appeal rights, or bed-hold policies**....
The incident at The Nichols Center occurred on October 3rd when Resident #1 called for assistance with incontinence....
The Honolulu facility has not submitted a plan of correction for the documented deficiency....
While this classification represents one of the lower severity tiers in the federal rating system, the finding carries significant clinical implications....
The facility has not submitted a plan of correction....
The facility never notified the New York State Department of Health about what happened....
The investigation ignored male residents entirely and failed to check other floors where the accused employee worked....
Both thresholds signal potentially life-threatening fluid retention in congestive heart failure patients....
However, even an isolated immediate jeopardy finding is a significant regulatory event....
The incident involved Resident 7, who was left alone while suspended in the lift as both nursing assistants exited the room....
R1 was "always in pain and complained when being turned and repositioned," according to a certified nursing assistant who cared for the resident....
The resident, identified only as Resident 3, had worn the wedding ring during a family visit in July 2025....
Resident #101 was supposed to receive blood sugar checks three times weekly under a doctor's order that began September 13, 2024....
The incident occurred on August 19 at 8:30 a.m....
The resident, identified as cognitively intact in facility assessments, was prescribed Gabapentin three times daily for pain and anxiety management....
At 9:08 on the morning of November 26, inspectors discovered the cart sitting unattended in the hallway....
The facility has **not submitted a plan of correction** for the identified deficiency....