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Complaint Investigation

Focused Care Of Gilmer

November 25, 2025 · Gilmer, TX · 623 Hwy 155n
Citations 2
CMS Rating 2/5
Beds 112
Provider ID 675602
Healthcare Facility
Focused Care Of Gilmer
Gilmer, TX  ·  View full profile →
Inspection Summary

Focused Care of Gilmer in Gilmer, TX — inspection on November 25, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0584
Resident Rights Deficiencies
Potential for More Than Minimal Harm

always deal with the urine odors in a timely manner. He stated he had never noticed Resident #3's call light going off to ask for staff assistance with emptying his urinal.

The Administrator stated he was unsure what the process was for emptying urinals but expected alert residents to be more involved with their care.

The Administrator stated it was important to ensure urine odors were managed because he would not have wanted to live or work in a facility that smelt bad.

Record review of the Quality of Life - Homelike Environment policy, revised May 2017, reflected The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting.

These characteristics include: .clean, sanitary and orderly environment. pleasant, neutral scents.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Focused Care of Gilmer

623 Hwy 155n Gilmer, TX 75644

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 11/25/25 at 2:03 PM, the Assistant Director of Clinical Operations stated she expected the CNAs to ensure infection control practices were at the forefront of their mind while performing incontinent or catheter care.

She stated the nursing management provided in-service education and check offs for incontinent and catheter care all the time.

The Assistant Director of Clinical Operations stated she understood the staff became nervous when state surveyors were watching, but she still expected them to follow the infection control practices during incontinent or catheter care.

She stated it was important to ensure infection control practices were followed during incontinent or catheter care to prevent the risk of urinary tract infections.

The clinical checkoffs for incontinent care were requested for CNA A and CNA B.

During an interview on 11/25/25 at 2:26 PM, the Director of Clinical Operations stated she expected the staff to ensure they were sanitizing their hands and changing gloves at the appropriate times during incontinent or catheter care.

She stated the staff completed checkoffs and online training and in-service education.

She stated next month several of the facilities were providing a skills fair that would have included incontinent care.

The Director of Clinical Operations stated it was important to ensure infection control practices were followed during incontinent or catheter care, so the staff did not contaminate other body openings and decreased the risk of UTIs.

She stated poor incontinent care could have contributed to Resident #1 and Resident #2's recurrent UTIs.

During an interview on 11/25/25 at 3:01 PM, the Administrator stated he expected the nursing staff to ensure the best practices were utilized when performing incontinent or catheter care.

The Administrator stated he did not have a clinical background and the administrative nursing staff were responsible for monitoring to ensure infection control practices were utilized during incontinent and catheter care. He stated it was important for infection control issues.

Record review of the Nursing Services - Competency Evaluation, dated 11/03/25, reflected CNA A met the performance criteria for incontinent care, with no comments noted.

Record review of the Nursing Services – Competency Evaluation, dated 11/03/25, reflected CNA B met the performance criteria for incontinent care, with no comments noted.

Record review of the Elimination, Perineal Care policy, effective 10/01/21, reflected To provide cleanliness and comfort to the resident, to prevent infections and skin irritation.

The policy did not address infection control practices related to incontinent or catheter care .

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Gilmer, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Focused Care of Gilmer or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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