Carrie Elligson Gietner Health Care Center

Based on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) seven days a week. This had the potential to affect all residents of the facility. The sample was five. The census was 86. Review of the facility's Sufficient Staffing Policy, dated February 2023, showed the following:-Purpose: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment.-Policy: -The facility is required to provide licensed nursing staff 24 hours a day, 7 days a week;- Except when waived, the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. Review of the facility's daily staffing sheets showed the following:-8/20 through 8/22/25, no RN scheduled;-8/25 through 8/31/25, no RN scheduled;-9/1 through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure recipes were followed while preparing pureed meals for one of one observed mealtime preparation. The census was 86.Observation on 9/22/25 at 11:05 A.M. of the kitchen, showed [NAME] D took one breaded chicken breast, placed it in a blender and added approximately one tablespoon of water and blended for approximately 45 seconds. Observation after blending, the breaded chicken breast appeared to be of ground meat consistency and not smooth. [NAME] D portioned the mixture into tin pans and placed it on the steamtable. Review of the facility's Pureed Breaded Chicken Breast recipe, dated 2025, showed the following:-One Serving: One breaded chicken breast, four tablespoons and two teaspoons of water and one fourth teaspoon of chicken base;-Combine chicken base and water to make chicken broth. Place prepared breaded chicken breasts in a sanitized food processor. Add broth and blend until smooth. During an interview on 9/22/25 at 11:15 A.M., [NAME] D said he/she should have followed the recipe for the pureed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to keep the kitchen walls clean and floors free of grease, dirt and grime for one of one day of observation. The census was 86.Review of the facility's Dietary Cleaning Duties, undated, showed the following:-Morning Crew: Wipe down all stainless surfaces, clean ovens and stove top, mop kitchen and dining room;-Evening Crew: Wipe down all stainless surfaces, clean ovens and stove top, mop kitchen and dining room;All employees must clock out with work completed at designated time. The cook on duty is responsible for checking that above duties are completed before they clock out. Manager is to assure this process is carried out. Observation on 9/22/25 of the kitchen, showed the following:-9:00 A.M., the floor under the refrigerator and along the back wall had dirt built up and grime;-9:02 A.M., the floor under the stove and fryer had built up grease and grime and the walls next to the fryer had built up grease and grime;-9:04 A.M., the floor under the coffee station had built up dirt and grime;-11:04 A.M., the walls…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to meet professional standards when staff failed to make an appointment and follow up with a urologist (specializes in the urinary and reproductive systems) as requested by the urologist for one resident. (Resident #4). The sample was five. The census was 86. Review of the facility's Transcription of Orders/Following Physician's Orders Policy, dated 5/18/24, showed the following:-Purpose: The purpose of this policy is to outline procedures in accurately transcribing physician's orders and to ensure that all physicians' orders are followed. To ensure a process is in place to monitor nurses in accurately transcribing and following physician's orders;-Procedure:-A. Upon receiving a physician's order via telephone, fax, written order, verbal order, transcribed order or other, it will be documented in residents' electronic medical records in orders section; -B. Clarification of Physician's Orders will be obtained if the order is either unclear or the nurse is uncomfortable in implementation of the Physician's Orders. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure medications on the 200 hallway, were stored properly for multiple residents, including two sampled (Residents #1 and #2), which had the potential to cause harm to all residents. The sample was five. The census was 87.Review of the facility's medication storage policy, dated 5/18/24, showed:-Policy: All drugs and biologicals will be stored in locked compartments, cabinets, drawers, refrigerators, under proper temperature control. Narcotics and controlled substance medications are stored under double lock and key;-Any discrepancies which cannot be resolved must be reported immediately as follows: Notify the Director of Nursing (DON), charge nurse, and the pharmacy. Complete an incident report detailing the discrepancy, steps taken to resolve it, and names of all licensed staff working when the discrepancy was noted. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies. 1. Observation on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to conduct a background screening for one hired employee (Administrator A). The facility failed to screen Administrator A to rule out the presence of a Federal Indicator, failed to conduct a Criminal Background Check (CBC), and Employee Disqualification List (EDL) check. The facility also failed to maintain records of the employment application, experience and education, references, license verification, and results of the background checks required by section 660.317 of Revised MO Statues. Administrator A was employed at the facility for approximately four months. This had the potential to affect all residents. The census was 86. Review of the facility's Abuse and Neglect policy, revised 6/12/24, showed: -This Facility will not employ individuals who have been convicted of abusing, neglecting or mistreating individuals. Potential employees are screened for a history of abuse, neglect or mistreating of residents; -This Facility is committed to protecting our residents from abuse by anyone including, but not limited to,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to maintain a qualified Administrator on duty. This had the potential to affect all residents. The census was 86. Review of the current Missouri Board of Nursing Home Administrators (MBNHA) license registry website, showed Administrator A not listed as a current Missouri Licensed Administrator. Review of Administrator A's Missouri Department of Health and Senior Services (DHSS) facility history, showed: -Administrator at Facility D on 10/14/24 through 11/5/24; -Administrator at Facility E on 11/7/24 through 3/19/25. During an interview on 4/2/25 at 10:30 A.M., Administrator B said he/she had been the Administrator of Facility E since 3/27/25. During an interview on 4/2/25 at 2:42 P.M., the Regional Director of Operations said he/she had been with the company since January 2025, so Administrator A was already employed at Facility E. Administrator A's license was checked along with new hires, but his/her name was not listed at all, not even inactive. Administrator A said he/she did not know why he/she was not on there and later…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY See the deficiency cited at Event KJ9713. Based on interview and record review, the facility failed to ensure staff maintained documentation of medication as provided on the medication administration record and treatment administration for two months for three of three sampled residents (Residents #11, #12 and #10). The census was 77. Review of the facility's Medication Administration policy, revised on 6/26/24, showed: -Purpose: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. It is the policy of the facility to ensure the safe and effective administration of all medications by utilizing best practice guidelines; -General medication administration process: -Ensure that the six rights of medication administration are followed: 1. Right resident; 2. Right drug; 3. Right dosage; 4. Right route; 5. Right time; 6.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY See the deficiency cited at Event KJ9713. Based on observation, interview and record review, the facility failed to ensure resident care plans were updated and accurate to reflect resident needs. This failure affected one of three sampled residents, whose care plan did not identify the resident's increased need for staff assistance with activities of daily living (ADLs) after falling and fracturing his/her arm (Resident #10). The sample was three. The census was 77. Review of the facility's Baseline Care Plan Policy revised on 5/18/24, showed: -The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care: -Policy: The baseline care plan will: -Include the minimum healthcare information necessary to properly care for a resident, including but not limited to: -Physicians orders; -Therapy services; -Social services; -The admitting nurse or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY See event ID #KJ9712. Based on observation, interview and record review, the facility failed to maintain effective pest control by ensuring resident rooms (Resident #4, #5, #3, #6, #7 and #8) were free from bed bugs (small, oval, brown insects that feed on the blood of animals and humans). This failure had the potential to affect all residents. The sample was nine. The census was 79. Review of the facility's Bed Bug Prevention and Management Policy, revised on 5/14/24, showed: -Purpose: Staff will implement measures to prevent, eradicate and contain bed bugs as a part of the facility's overall pest control program; -Policy: The facility shall take a systematic approach to bed bug prevention and management, including monitoring and detection, treatment of affected resident(s), eradication of pests and prevention of recurrence; -Monitoring and detection: -Bed bugs can be hard to find and identify given their small size and their habit of staying hidden; -Bed bugs usually travel on belongings, not people; -Bites on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure staff maintained documentation of medication as provided on the medication administration record and treatment administration for two months for three of three sampled residents (Residents #11, #12 and #10). The census was 77. Review of the facility's Medication Administration policy, revised on 6/26/24, showed: -Purpose: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. It is the policy of the facility to ensure the safe and effective administration of all medications by utilizing best practice guidelines; -General medication administration process: -Ensure that the six rights of medication administration are followed: 1. Right resident; 2. Right drug; 3. Right dosage; 4. Right route; 5. Right time; 6. Right documentation; -Sign medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to maintain effective pest control by ensuring resident rooms (Resident #4, #5, #3, #6, #7 and #8) were free from bed bugs (small, oval, brown insects that feed on the blood of animals and humans). This failure had the potential to affect all residents. The sample was nine. The census was 79. Review of the facility's Bed Bug Prevention and Management Policy, revised on 5/14/24, showed: -Purpose: Staff will implement measures to prevent, eradicate and contain bed bugs as a part of the facility's overall pest control program; -Policy: The facility shall take a systematic approach to bed bug prevention and management, including monitoring and detection, treatment of affected resident(s), eradication of pests and prevention of recurrence; -Monitoring and detection: -Bed bugs can be hard to find and identify given their small size and their habit of staying hidden; -Bed bugs usually travel on belongings, not people; -Bites on skin are a poor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the Department of Health and Senior Services (DHSS) within the required timeline after two residents reported a staff member verbally abused them (Resident #1 and Resident #2). Staff also failed to report the abuse to facility administration in a timely manner. The sample size was four. The census was 80. Review of the facility's Abuse and Neglect policy dated 7/25/24, showed: -Purpose: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed time frames; -Definitions: -Verbal abuse: Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure they followed their abuse and neglect policy by failing to conduct a thorough investigation into one resident's (Resident #1) allegation a Certified Nursing Assistant (CNA) cursed and threatened him/her on 10/19/24. The resident reported the allegation on 10/19/24 and on 10/20/24 when he/she saw the CNA back at the facility. The facility initiated an investigation on 10/19/24, but failed to thoroughly interview all staff involved, interview other residents, document verbal statements and make appropriate notifications. The census was 80. Review of the facility's Abuse and Neglect policy dated 7/25/24, showed: -Purpose: It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure resident care plans were updated and accurate to reflect resident needs. This failure affected one of three sampled residents, whose care plan did not identify the resident's increased need for staff assistance with activities of daily living (ADLs) after falling and fracturing his/her arm (Resident #10). The sample was three. The census was 77. Review of the facility's Baseline Care Plan Policy revised on 5/18/24, showed: -The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care: -Policy: The baseline care plan will: -Include the minimum healthcare information necessary to properly care for a resident, including but not limited to: -Physicians orders; -Therapy services; -Social services; -The admitting nurse or supervising nurse on duty, shall gather information…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure food was prepared separate from dish cleaning and failed to ensure floors and walls in the kitchen were clean and free from debris, fans in the dish washing room free from dust build up, ceiling lights above the food prep station free from dust accumulation, and that the dry food storage rack was free from debris. The census was 79. Review of the facility's dietary cleaning duties, undated, showed: -Morning crew: mop kitchen and dining room, wipe down all racks, fridges, and freezers; -Evening crew: mop kitchen; -Weekly: dietary supervisor to clean all equipment that may emit dust, lint, or grease residue in the kitchen, dining room, dishwasher room, and all dietary storage areas. 1. Observation of lunch preparation on 6/25/24, showed: -At 8:52 A.M., the Dietary Supervisor opened bags of raw chicken and placed chicken into the sink; -At 8:55 A.M., [NAME] H brought two pans over to the sink next to where the chicken was and started to clean the dishes; -At 8:56 A.M., water from the sink where dishes were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one resident's (Resident #7's) advanced directive matched in the hard (paper) chart and on the physician's orders sheet (POS) and that one resident (Resident #72) had a current physician's order for code status. The facility also failed to ensure the resident's advanced directives were reviewed annually (Residents #62, #25, #2, #19, #26, #41). The sample was 18. The census was 79. Review of the facility's advanced directives policy, revised [DATE] showed: -Policy: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy; -Policy implementation: The interdisciplinary team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that in accordance with acceptable professional standards and practices, medical records were complete and accurately documented including the administration of medications and treatments for five residents (Resident #50, #20, #67, #7, and #51). The sample was 18. The census was 79. Review of the facility's undated Administering Medication Policy, showed: -Policy statement: medications shall be administered in a safe and timely manner, and as prescribed; -Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so; -The Director of Nursing (DON) Services will supervise and direct all nursing personnel who administer medications and/or have related functions; -The individual administering the medication must initial the resident's Medication Administration Record (MAR) on the appropriate line after giving each medication and before administering the next ones; -If a dug is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure residents were assessed to self-administer medications and physician orders were maintained for self-administration of medication for two residents observed with medications left at the bedside (Residents #42 and #62) and one resident who was not adequately supervised during medication administration (Resident #77). The sample was 18. The census was 79. Review of the facility's Self-Administration of Medications policy, revised February 2021, showed: -Policy Statement: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; -Policy Interpretation and Implementation: -As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident; -If it is deemed safe and appropriate for a resident to self-administer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide a homelike environment for one resident when staff failed to ensure the hot water faucet in the resident's was functioning properly (Resident #67). The sample was 18. The census was 79. Review of Resident #67 medical record, showed: -Diagnoses of depression, Alzheimer's disease, high blood pressure, high cholesterol, and mood disorder; -A Care Plan, dated 4/5/24, showed the resident can shower independently, requires only set up as needed. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/5/24, showed: -Cognitively is intact; -Requires setup or clean-up assistance with showering or bathing. Observation and interview on 6/24/24 at 9:17 A.M., showed the hot water faucet located in the resident's bathroom did not function properly, when turned on, no water was produced. The resident said he/she prefers to bath in the sink located in his/her room because of the time it takes the staff to get him/her to the shower room.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to implement and document a discharge planning process involving the legal guardian for one resident (Resident #36) with an expressed interest in transitioning to a placement with a lower level of care. The sample was 18. The census was 79. Review of the facility's Discharge Summary and Plan policy, revised October 2022, showed: -Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan; -The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family; -The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge; -The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan; -Residents are asked about their interest in returning to the community. If the resident indicates an interest in returning to the community, he or she will be referred to local agencies and support services that can assist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure five residents who required assistance with activities of daily living (ADL) received personal care, nail care, and facial hair hygiene in accordance with their needs and preferences (Residents #2, #19, #20, #7 and #17). The sample was 18. The census was 79. Review of the facility's undated perineal (area including and between the genitals, hips and anal area) care policy, showed: -Purpose: to provide cleanliness and comfort to the resident, to prevent infection, skin irritation and observe the skin condition; -Steps in the procedure: -Wash perineal area, cleaning front to back; -Separate the skin continuing to cleanse in a front to back motion; -Move from inside outward to the thighs. Rinse the skin in a same manner; -Clean the rectal area, front to back of the buttocks. Rinse and dry thoroughly. Review of the facility's undated ADL policy, showed: -Statement: Residents will be provided with care, treatment and services as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure neurological assessments were completed and documented for two of two sampled residents who experienced falls (Residents #42 and #79). The facility also failed to secure and lock the 200 unit medication cart. The sample was 18. The census was 79. 1. Review of the facility's undated fall policy, showed: -The nurse should assess and document and report vital signs, injury especially if a head injury, changes in range of motion, change in cognition or level of consciousness, neurological status, pain, frequency and number of falls since the last physician visit, factors on how the fall occurred, all medications and active diagnoses; -The staff will evaluate and document falls that occur while the individual is at the facility, for example when and where the fall happens, observations of the events; -Falls should be identified as witnessed or unwitnessed; -Monitoring and follow-up: -The staff, with the physician's guidance will follow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when one resident (Resident #51) was not administered the ordered dose of Lasix (diuretic) for over two weeks. The sample was 18. The census was 79. Review of the facility's undated Medication Orders policy, showed: -The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders; -When recording orders for medications, specify the type, route, dosage, frequency, and strength of the medication ordered. Review of the facility's undated Administering Medications policy, showed: -Medication are administered in a safe and timely manner, and as prescribed; -Medications are administered in accordance with prescriber orders, including any required time frame. Review of Resident #51's medical record, showed: -Diagnoses included high blood pressure, diabetes, anxiety, high cholesterol, and pain; -An order, dated 6/10/24, for Lasix 20 milligrams (mg) by mouth daily for seven days. Obtain blood pressure for seven days,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to maintain a clean, sanitary kitchen and food storage areas as evidenced by: a. undated, unlabeled, unsealed food in the refrigerators and freezers, b. dried food debris on the manual can opener blade, c. bulk food containers and storage units with debris on the outsides, d. food smears and debris on the outsides of refrigerators and freezers, e. food debris on the plate warmer plate holders, f. food containers on food preparation counters not labeled/dated and/or soiled, g. no documentation of sanitizer concentration testing of dish machine and 3-compartment sink, and h. no documentation of completed cleaning checklists. This had the potential to affect all 71 residents who resided in the facility and ate food prepared in the kitchen. Findings included: A review of the facility's Food Receiving and Storage policy, dated October 2017, revealed, Foods should be received and stored in a manner that complies with safe food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, and facility policy review, the facility failed to ensure written information was provided to residents and/or their representatives regarding the right to formulate an advance directive and failed to ensure assistance with formulating an advance directive was offered for 3 (Resident #61, Resident #43, and Resident #47) of 3 sampled residents reviewed for advance directives. Findings included: Review of a facility policy titled, Advance Directives, revised 12/2016, revealed, 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law. 3. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. 4. If the resident becomes able to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview, document review, and document review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123 was provided to residents or their representatives prior to the end of Medicare Part A services when the residents' benefit days were not exhausted, that advance beneficiary notices (ABNs) of non-coverage were dated, and that the residents'/representatives' decision whether to continue services was indicated on the forms for 3 (Residents #7, #57, and #66) of 3 sampled residents reviewed for beneficiary notices. Findings included: 1. Review of a face sheet revealed Resident #7 had diagnoses that included schizophrenia, bipolar disorder, and osteoarthritis. Review of a SNF [Skilled Nursing Facility] Beneficiary Notification Review form for Resident #7 revealed the resident's Medicare Part A skilled services episode start date was 08/02/2022, and the last covered day of Part A service was 09/15/2022. The form indicated the facility initiated the discharge from Medicare Part A services when the resident's benefit days were not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, facility document review, and facility policy review, the facility failed to ensure staff under investigation for allegations of abuse were suspended in accordance with the facility's abuse prohibition policies and procedures for one staff member out of 5 staff reviewed in relation to abuse allegations. Findings included: Review of a facility policy titled, Abuse Investigation and Reporting, revised July 2017, revealed, The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 1. Review of a face sheet revealed Resident #281 had diagnoses that included mild mental retardation, post-traumatic stress disorder (PTSD), dementia, and paranoid schizophrenia. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #281 had a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident had moderate cognitive impairment. According to the MDS, Resident #281 exhibited no behaviors…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, facility document review, and facility policy review, it was determined that the facility failed to report allegations of abuse to the state- when reported to the facility by Resident #281. Findings included: A review of a facility policy titled, Abuse Investigation and Reporting, revised July 2017, indicated, Reporting: 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. During the entrance conference conducted on 10/31/2022 at 10:13 AM with the Owner, the Administrator (ADM), and the Director of Nursing (DON), the facility was asked to provide reports of allegations of abuse for the past 12 months. The Owner stated there…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected residents' dental status for 2 (Resident #48 and Resident #60) of 3 residents reviewed for dental needs. Findings included: During an interview on 11/04/2022 at 8:30 AM, the Director of Nursing (DON) was asked for a facility policy regarding completion/accuracy of MDS assessments. No policy was provided prior to the conclusion of the survey. 1. Review of a face sheet revealed Resident #48 had diagnoses that included stroke, cognitive impairment, and diabetes. Observation of Resident #48 on 10/31/2022 at 2:32 PM revealed the resident had no teeth. Review of an annual MDS dated [DATE] revealed Resident #48 had modified independence in cognitive skills for daily decision-making per a staff assessment of mental status. The MDS indicated the resident was totally dependent for personal hygiene. Section L Oral/Dental Status was not accurately completed to indicate the resident had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure facility staff treated two residents (Resident #34 and #21) with respect and dignity. Findings included: 1. Review of a face sheet revealed Resident #34 had diagnoses that included psychosis and arthritis. Review of an annual Minimum Data Set (MDS), dated [DATE], revealed Resident #34 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. According to the MDS, the resident had delusions and exhibited verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and rejection of care on one to three days of the seven-day assessment period. Review of a Care Plan, dated 08/04/2022, revealed Resident #34 became annoyed easily and yelled and cursed at peers and staff and did not like people in their room or touching their things. During an interview with the surveyor on 10/31/2022 at 3:57 PM, Resident #34 alleged that CNA #7 was disgusting and abusive. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure self-administration of medication was clinically appropriate for 1 (Resident #46) of 1 resident reviewed for self-administration of medications. Observations revealed Resident #46 had an inhaled medication at the bedside and interviews revealed the resident self-administered the medication. Review of the record and interviews with staff revealed no evidence the facility had assessed the resident to be clinically appropriate to self-administer the medication. Findings included: A review of the face sheet revealed the facility admitted Resident #46 with diagnoses that included anxiety, depression, lower leg osteomyelitis, and edema. A review of a progress note of an eye examination for Resident #46, dated 11/22/2021, indicated Resident #46 had age-related cataracts, bilaterally, causing significant blurred vision. A review of the quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #46 had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to personal privacy was maintained for 1 (Resident #33) of 2 residents reviewed for privacy. Observations revealed there was no door or privacy curtain that would maintain privacy during toileting for Resident #33. Findings included: A review of Resident #33's face sheet indicated the facility admitted the resident with diagnoses that included depression, schizophrenia, psychosis, schizo-affective schizophrenia, and suicidal ideations. A review of Resident #33's 5-day Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score was 12, indicating the resident had moderately impaired cognition. The MDS indicated the resident required supervision for all activities of daily living. A review of the resident's Multi-Disciplinary Problem Oriented Care Plan, last reviewed on 09/15/2022, indicated Resident #33 was continent of bowel and bladder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, it was determined that the facility failed to develop a care plan that included trauma-informed interventions to address post-traumatic stress disorder (PTSD) for 1 (Resident #281) of 4 sampled residents reviewed for care plans. Findings included: Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also indicated, 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of a face sheet revealed the facility admitted Resident #281 on 06/09/2021 with diagnoses which included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, review of the facility policy, and record review, the facility failed to revise a care plan for 1 (Resident #3) of 22 residents reviewed for care plans. Specifically, the facility failed to revise the care plan to include interventions to prevent skin tears for Resident #3. Findings included: A review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy indicated the care plan reflects currently recognized standards of practice for problem areas and conditions. The policy also indicated, 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A review of the face sheet for Resident #3 indicated the facility admitted the resident with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure the environment was as free of accident hazards as possible and interventions to prevent further skin tears were developed and implemented for 1 (Resident #3) of 3 sampled residents reviewed for accidents. Specifically, record review revealed the resident had a history of skin tears and observations revealed Resident #3 had a skin tear to the right arm with no interventions in place to prevent further skin tears. Additionally, observations revealed Resident #3's wheelchair had peeling vinyl on the armrest, creating a risk for further skin tears. Findings included: Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS indicated the resident required extensive assistance with transfers. The MDS did not indicate the resident had skin tears at the time of the assessment. Review of a Care Plan, dated as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure the medication error rate was less than 5%. Observation of medication administration revealed there were 2 medication errors in 27 opportunities for error, resulting in a medication error rate of 7.41%. Findings included: A review of the facility policy titled, Administering Medications through a Metered Dose Inhaler, revised in October 2010, indicated in Paragraph 14, Administer medication: to d. Ask the resident to inhale and exhale deeply for a few breath cycles. On the last cycle, instruct the resident to exhale deeply. e. Place the mouthpiece in the mouth and instruct the resident to close his or her lips to form a seal around the mouthpiece. f. Firmly depress the mouthpiece against the medication canister to administer medication. g. Instruct the resident to inhale deeply and hold for several seconds. The policy further indicated, Repeat inhalation, if ordered. Allow at least one (1) minute between inhalations of the same medication and at least two (2) minutes between…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record reviews, and review of a facility policy, the facility failed to provide routine dental care for 2 (Resident #48 and Resident #60) of 3 residents reviewed for dental care. Findings included: The facility's policy titled, Availability of Services, Dental with a revision date of August 2017, indicated Oral healthcare and dental services will be provided to all residents. The policy also indicated under Paragraph 1 that Dental services are available to all residents requesting routine and emergency dental care. 1. A review of the face sheet for Resident #48 indicated the facility admitted the resident with diagnoses that included stroke, cognitive impairment, hypertension, diabetes, and depression. A review of Resident #48's annual Minimum Data Set (MDS), dated [DATE], indicated the resident had modified independence (some difficulty in new situations only) with cognitive skills for daily decision making based on the staff assessment of mental status and both the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a wheelchair was maintained in safe operating condition to prevent potential injury for 1 (Resident #5) of 2 sampled residents reviewed for wheelchair use. Findings included: Review of a facility policy titled, Assistive Device and Equipment, revised January 2020, revealed, Our facility maintains and supervises the use of assistive devices and equipment for residents. The policy also indicated, Devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired. Review of a face sheet revealed Resident #5 had diagnoses including an above-the-knee amputation and diabetes. Review of an admission Nursing Assessment, dated 04/09/2021, revealed Resident #5's ambulation status was wheelchair only and wheelchair/propels self. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #5 had a Brief Interview for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.