Carrie Elligson Gietner Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to initiate a Code Purple (protocol for resident who eloped from an off-site location) in accordance with facility policy for one resident (Resident #1) who signed him/herself out for an appointment on 07/14/26 and did not return to the facility. The resident signed him/herself out of the facility on 07/14/26 at 12:58 P.M. with an expected return time of 4:30 P.M., but the resident did not return. Staff were aware the resident did not return as expected and did not communicate this to the subsequent shifts on 07/14/26 and 07/15/26, who failed to initiate the Code Purple. Staff failed to make efforts to locate the resident until 07/16/26, after Department of Health and Senior Services (DHSS) began an onsite visit and Administration became aware the resident was missing. The resident's whereabouts were unknown for 48 hours. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and address nutritional needs and swallowing difficulties for one resident who was at risk for impaired nutrition and hydration. The resident experienced a significant weight loss of 20.52 % in three months (Resident # 2). The sample size was 20. The census was 97. Review of the facility's Nutritional Management policy, last revised on 5/18/24, showed:-Purpose: The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition;-Definitions: Acceptable parameter of nutritional status is inadequate, relative to his/her overall condition and prognosis, such as weight, food and fluid intake, and pertinent lab values; [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, monitor, and address behavioral health needs related to substance use disorder for residents with known history of substance abuse, including a thorough review of the referral information identifying recent substance use and positive toxicology results. The facility also failed to implement appropriate behavioral health interventions, monitoring, and services during a period in which social services staff were unavailable, resulting in missed opportunities to identify relapse risk, escalating warning signs, and ongoing substance use within the facility (Residents #104, #105, and #101). The resident sample was 20. The census was 97. The administrator was notified on [DATE], of the past non-compliance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food storage, dishwasher sanitizing, and cleaning was in accordance with professional standards of practice, increasing the risk of cross-contamination and food-borne illness. In addition, there was no air gap between the ice machine and drain. This deficient practice had the potential to affect all residents who were served food from the kitchen. The census was 97. Review of dietary cleaning duties list, received 5/21/26, showed:-Morning Crew: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms (Resident #2), resident common area meeting spaces, and resident belongings were kept in a clean, safe, and homelike manner. Concerns were noted with shower rooms on the 300, 500 and 100 hall, resident phone rooms, and with the sunrooms at the ends of resident halls. The sample size was 20. The census was 97. Review of the facility's Safe and Homelike Environment policy, revised 6/5/24, showed:-In accordance with the residence rights, the facility will provide a safe, clean, comfortable, and home like environment, allowing the resident to use his or her personal belongings to the extent possible. [...]

Inspectors wroteBased on interview and record review the facility failed to send a copy of the transfer and discharge notices to a representative of the Office of the State Long-Term Care Ombudsman (resident advocate) for January, February, March, and April 2026. The census was 97. Review of the facility's Resident Transfer, Discharge, Immediate Discharge, and Therapeutic Leave policy, last revised 4/28/25, showed:-Purpose: Establish policy and procedure regarding the transfer/discharge of residents; To ensure no inappropriate discharges are made and that no discharges are made in an unsafe manor;-Notice of discharge or transfer: -Who must receive notice; -Notifying the representative for the Office of the State Long-Term Ombudsman; -A copy of the discharge transfer notice shall be sent to the Ombudsman at least 30 days in advance of the discharge or as soon as possible; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received appropriate activities of daily living (ADL, daily care) care to meet the needs of residents by not assisting three residents with their showers (Resident # 35, Resident #25 and Resident #2) and provide foot care for one resident (Resident #25). The facility also failed to assist one resident during mealtimes (Resident #55). The sample size was 20. The census was 97. Review of the facility's ADL policy, dated 5/18/24, showed:-Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activity program that supports resident's interests and their choices of activities for three residents (Residents #7, Resident #25, and Resident #8). In addition, the facility failed to provide one to one (1:1) activities to one resident who was identified as having the potential to benefit from them (Residents #35). The sample size was 20. The census was 97. Review of the facility's Activities policy, last revised on 7/19/23, showed:Purpose: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure smoking assessments were completed for three residents (Residents #91, #2, and #31) and failed to ensure lighters and cigarettes were not taken in two residents' rooms (Residents #91 and #2). The sample was 20. The census was 97. Review of the facility's Smoking Safety Regulations Policy, dated 6/29/23, showed: -The facility will provide direct supervision for smoking by patients classified as not responsible; -The policy did not address the frequency of smoking assessments; -The policy did not address the storage locations of smoking materials. 1. Review of Resident # 91's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/28/26, showed: -Diagnoses included cancer, chronic (long term) lung disease, seizures, and stroke; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure employee two-step tuberculin skin tests were completed in accordance with State guidelines for nine of 10 sampled employees. The census was 97. Review of the facility's tuberculosis (TB) testing policy, dated 6/29/23, showed:-Purpose: To ensure each resident and employee of the facility is tested for TB after entering the facility to prevent the spread of infection;-Procedure: Upon hire a new employee will receive a two step purified protein derivative (PPD) skin test. Each employee will also have an annual one step TB test to ensure that any possible infections can be triggered proactively to prevent further spread. 1. Review of Employee AA's personnel file, showed:-Hire date of 5/28/25;-No documentation of first step TB test being administered;-No documentation of second step TB test being administered. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Notice of Medicare Non-Coverage (NOMNC) was given to three of three sampled residents who remained in the facility upon discharge from Medicare Part A services (Residents #9, #21, and #75). The census was 97. Review of the facility's Advanced Beneficiary Notice policy, dated 11/5/24, showed:-Purpose: To ensure the facility provides timely notices regarding Medicare eligibility and coverage;-Policy: A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility or remaining in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services for two residents (Resident #101 and #104) by failing to assess, monitor, and respond to signs and symptoms associated with substance use and overdose. The facility failed to ensure ongoing medical monitoring following an overdose that required Narcan (life-saving medication used to rapidly reverse opioid overdoses) administration (Resident #101). The facility failed to assess, evaluate, and implement interventions following observed behavioral changes and signs consistent with substance use or withdrawal, resulting in missed opportunities to identify and address ongoing substance related risks (Resident #104). The sample size was 20. The census was 97. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications and biologicals were removed from medication carts and medication rooms in the facility. Concerns were noted with two of two medication rooms and one of four medication carts reviewed for the survey. The resident sample was 20. The census was 97. Review of the facility's Medication Storage Policy revised 5/18/24, showed:-All drugs and biologicals will be stored in locked compartments under proper temperature controls;-Only authorized personnel will have access to the keys to locked compartments;-The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with the medication destruction policy. 1. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide protective oversight for one resident, (Resident #1), when the facility failed to follow their weather advisory procedures regarding going outdoors in extreme heat. The failure put this resident, who was prescribed two medications that could affect the body's ability to regulate temperature, at an increased safety risk due to the extreme heat. The resident was outside of the facility, without supervision, from 9:00 A.M. until approximately 4:00 P.M., during a heat advisory. The resident reported to facility administration that after purchasing cigarettes, he/she became overheated and lost consciousness in someone's backyard for an unknown length of time. The resident was admitted to the hospital on [DATE] at 4:28 P.M. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteSee the deficiency cited at Event KJ9713. Based on interview and record review, the facility failed to ensure a resident (Resident #10) kept all appointments with the orthopedic surgeon after an unwitnessed fall resulting in a fracture of his/her right arm on 9/13/24. Delay of treatment has caused pain and a decrease in his/her ability to perform activities of daily living (ADLs). The sample was three. The census was 77. Review of the facility's Resident Appointment policy, updated on 8/24, showed: -Purpose: To ensure all appointments and follow-up appointments (as needed) are scheduled. Residents will be taken to all scheduled appointments (barring emergency circumstances that require rescheduling). The facility is responsible in assisting with appointment management and scheduling/coordination of transportation (if requested/needed); -Procedure: [...]

Inspectors wroteSee the deficiency cited at KJ9713. Based on observation, interview, and record review, the facility failed to consistently assess pain or provide treatment in a timely manner for one resident (Resident #10) who fell and fractured his/her arm on 9/13/24. The resident missed a surgery date on on 10/23/24 after staff fed the resident, which resulted in the surgery being canceled. The facility failed to ensure the resident was seen by his/her orthopedic physician despite several attempts by the office to set up appointments since the postponed surgery or set up a new date for the surgery. The facility also failed to complete a new pain assessment after the resident's arm was fractured. These failures resulted in pain and a loss of mobility for the resident. The sample was three. The facility census was 77. Review of the facility's Pain Management policy revised on 6/26/24, showed: -Purpose: [...]

Inspectors wroteSee 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: [...]

Inspectors wroteSee 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: [...]

Inspectors wroteSee 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: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident #10) kept all appointments with the orthopedic surgeon after an unwitnessed fall resulting in a fracture of his/her right arm on 9/13/24. Delay of treatment has caused pain and a decrease in his/her ability to perform activities of daily living (ADLs). The sample was three. The census was 77. Review of the facility's Resident Appointment policy, updated on 8/24, showed: -Purpose: To ensure all appointments and follow-up appointments (as needed) are scheduled. Residents will be taken to all scheduled appointments (barring emergency circumstances that require rescheduling). The facility is responsible in assisting with appointment management and scheduling/coordination of transportation (if requested/needed); -Procedure: -Nursing staff to assist with scheduling appointments and follow-up if needed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently assess pain or provide treatment in a timely manner for one resident (Resident #10) who fell and fractured his/her arm on 9/13/24. The resident missed a surgery date on on 10/23/24 after staff fed the resident, which resulted in the surgery being canceled. The facility failed to ensure the resident was seen by his/her orthopedic physician despite several attempts by the office to set up appointments since the postponed surgery or set up a new date for the surgery. The facility also failed to complete a new pain assessment after the resident's arm was fractured. These failures resulted in pain and a loss of mobility for the resident. The sample was three. The facility census was 77. Review of the facility's Pain Management policy revised on 6/26/24, showed: -Purpose: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status to the extent possible, for one resident (Resident #34) who experienced a significant weight loss of 20 pounds from a weight on 5/14/24 of 136.6 pounds to 116.0 pounds on 6/26/24, resulting in a 15% weight loss in 6 weeks. During this timeframe, the facility's Registered Dietician (RD) completed a nutritional assessment and recommended health shakes three times a day. Staff failed to provide the supplements as ordered. The sample was 18. The census was 79. Review of the facility's undated nutrition/unplanned weight loss policy, showed: -Assessment and recognition: -Nursing staff will monitor and document the weight and dietary intake of residents; [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff treated two residents (Resident #34 and #21) with respect and dignity.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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%.

Inspectors wroteBased 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.

Inspectors wroteBased 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.