Gallatin Rest Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened food products were labeled with the date opened, and failed to properly store opened food products after opening. The failure placed all residents receiving food from the kitchen at increased risk of receiving expired, contaminated, or deteriorated food products.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from physical abuse by agency staff for 1 (#27); failed to ensure a resident was free from verbal abuse by agency staff for 2 (#s 39 and 60); failed to ensure a resident was free from physical and verbal abuse by another resident for 2 (#s 46 and 59); and failed to ensure a resident was free from neglect of care for 1 (#13) of 8 residents sampled for abuse. The failure placed the residents at risk for physical injury, emotional distress, diminished quality of life, and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of abuse for 7 (#s 13, 27, 37, 39, 46, 55 and 59) of 8 residents sampled for abuse. The failure resulted in incomplete investigations, which did not show the evaluation of ongoing actions taken for the residents' well-being, did not identify resident-specific interventions, revise care planning, or document other measures implemented to protect residents and prevent recurrence of similar incidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the risks and benefits associated with the use of a wander guard alarm and obtain informed consent for 1 (#1) of 5 residents sampled for wandering. The failure placed the resident at risk for restriction of movement and psychosocial distress; and failed to ensure a door to the outside of the facility was checked for eloping residents when alarmed, which had the potential to affect 5 residents who wander (#s 1, 3, 11, 18, and 34) of 23 sampled and supplemental residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff adhered to infection control processes during an ostomy bag change and peri-care for 1 (#29); failed to perform proper hand hygiene and glucometer sanitizing during medication administration for 1 (#14); and failed to ensure enhanced barrier precautions were implemented for 1 (#40) of 23 sampled and supplemental residents. These deficient practices increased the risk of the spread of infections for residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement, and maintain an effective behavioral health training program for all staff. This deficient practice had the potential to affect resident #14 and all other residents with behavioral health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice when they did not use a resident's respiratory therapy (CPAP) equipment, failed to notify the resident's provider, and failed to document the reason for the non-use of CPAP therapy for 1 (#5) of 15 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the safety and appropriateness of bed rail use and obtain informed consent for the use of two upper side rails for 1 (#49) of 23 sampled and supplemental residents. The failure placed the resident at risk for injury related to bed rail use, including entrapment, falls, and restriction of movement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain necessary services for the behavioral health care needs of 1 (#14) of 15 sampled residents. This deficient practice increased the risk of declining mental health for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure all the irregularities noted by the pharmacist on the monthly medication regimen review were addressed and documented in the resident's medical record for 2 (#s 5 and 13) of 15 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of staff education of the risks and benefits associated with the COVID-19 vaccine and documentation of the COVID-19 vaccination status for all staff members.

Inspectors wrote2. During an observation on 6/5/25 at 7:57 a.m., resident #13 received morning cares from staff members F and K. Resident #13 was lying on her back in the bed. Resident #13 had a wound dressing on her right heel which was left in place. When resident #13 was turned to her right side for incontinence care, an open area was noted on her coccyx. There was no wound dressing in place. Staff member F applied moisture barrier cream, and a new incontinence brief. Resident #13 called out in pain and cried when she was moved in her bed. The crying stopped as soon as the resident was left alone. During an interview on 6/4/25 at 12:47 p.m., staff member G stated the wound nurse had been seeing the resident weekly, otherwise staff did the dressing changes. Review of resident #13's nursing progress notes showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise resident care plans for 3 (#s 13, 32, and 43) of 21 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper hand hygiene for 4 (#s 14, 16, 21, and 208) of 7 observed medication passes; failed to maintain cleanable surfaces on floor mats for 2 (#s 1 and 36) of 2 sampled residents with floor mats; failed to maintain clean respiratory equipment for 1 (#36) of 6 sampled residents with respiratory equipment; and failed to properly store tube feeding supply sanitarily for 1 (#1) of 1 sampled resident with tube feeding supplies. These deficient practices had the potential to increase the risk of infections and spread of infections for all residents receiving care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident, and the resident's representative, were made aware of the risks and benefits associated with the use of psychotropic medications prior to the start of treatment for 1 (#32) of 21 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fully investigate an allegation of theft to ensure no other residents were affected for 1 (#34) of 21 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize a system for identifying root causes for falls, and failed to develop and implement individualized fall prevention strategies for 1 (#32) of 21 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have policies for dialysis care and management, policies for dialysis transportation, a contract and communication with the dialysis center providing dialysis treatment, and failed to have proper dialysis monitoring of the resident before and after dialysis appointments, for 1 (#207) of 1 sampled resident for dialysis.

Inspectors wroteBased on observations and interviews, the facility failed to provide residents with meals with no more than 14 hours between the evening meal and breakfast; failed to provide a nourishing snack at bedtime; and failed to document a resident group approval of the mealtime hours for 7 (#s 2, 9, 17, 18, 19, 21, and 28) of 13 sampled residents. This practice had the potential to affect all residents who receive meals from the dining service.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure implementation and monitoring of measures to prevent the growth of Legionella or other opportunistic waterborne pathogens in the building's water systems; and maintain cleanable surfaces on ice/water dispenser machine. This practice had the potential to affect all residents.