Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carrie Elligson Gietner Health Care Center during CMS and state inspections, most recent first.
Failure to Identify and Monitor Behavioral Health Needs Related to Substance Use: The facility did not adequately assess or monitor residents with known SUD histories and recent signs of relapse. A resident with opioid withdrawal, fentanyl use disorder, and polysubstance use disorder showed erratic behavior, withdrawal signs, and self-injury, while staff documented concerns but did not clearly communicate withdrawal from illegal drugs to the physician. Another resident with psychoactive substance abuse was found unresponsive with labored respirations, required Narcan and CPR, and was later on a Narcan drip. The record also showed narcotics found in a resident’s purse and room, with police involvement after the resident admitted recent fentanyl and methamphetamine use.
Dirty resident rooms and common areas were observed throughout the facility, including a resident’s room with stained linens, food debris, and cups of undigested food on the floor. Shower rooms on multiple halls had trash cans blocking access, mildew-like odors, dirty towels, hair, and used washcloths left on the floor, while the resident phone room and sunrooms had sticky stains, trash, a dead cockroach, cigarette ash, and dusty surfaces. Staff said these areas were cleaned daily and as needed, but observations showed they were not maintained in a clean, safe, and homelike manner.
A facility failed to provide consistent ADL assistance for several residents who needed help with bathing, grooming, foot care, and eating. Surveyors found missed or poorly documented showers, a resident with matted hair and dandruff who reported infrequent bathing and being told no due to staffing or equipment issues, another resident with dry feet and jagged toenails who had not received foot care, and a resident who avoided showers because the shower room was dirty and lacked shower shoes. During meals, a resident who required supervision/touch assist struggled to open a milk carton and use utensils while CNA coverage was present but did not assist.
Failure to Monitor and Respond to Substance Use and Overdose: The facility did not adequately assess or document care for two residents with substance use concerns. One resident had a drug overdose requiring Narcan, but the record lacked ongoing monitoring such as neuro checks and VS after the event. Another resident with a history of opioid and polysubstance use showed erratic behavior, self-picking, refusal of evaluation, and signs consistent with withdrawal, yet staff did not continue assessment or document the symptoms despite later discovery of fentanyl and methamphetamine in the resident’s possession.
The facility did not ensure an RN was present for at least 8 consecutive hours each day, as required, with staffing records showing multiple days without any RN coverage. The DON confirmed only two RNs were employed and was unaware that the DON could not also serve as the floor RN at the same time, potentially affecting all residents.
A staff member did not follow the facility's recipe for pureed breaded chicken breast, resulting in an improper consistency, and prepared pureed mixed vegetables without a standardized recipe, leading to small lumps in the final product. The Dietary Manager confirmed the lack of a recipe for mixed vegetables and stated that recipes are expected to be followed to ensure proper nutrition.
Surveyors observed significant build-up of dirt, grease, and grime on kitchen floors and walls, including under major appliances and behind sinks. Despite established cleaning protocols requiring daily deep cleaning by dietary staff, interviews revealed that restrictions on overtime and insufficient labor hours led to incomplete cleaning tasks. Facility management was aware of the ongoing cleanliness issues.
Staff did not schedule or document an urgent urology appointment for a resident with prostate cancer after a physician's order, resulting in the resident being turned away at the doctor's office and a lack of follow-up until much later. The facility's policy for transcribing and following physician orders was not followed, and required documentation was missing from the medical record.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents, resulting in an increased risk of incidents.
Staff failed to store medications in locked compartments as required, leaving multiple boxes of medication cards, some labeled with residents' names and containing prescription drugs, in open and accessible areas behind the nurse's station. Two residents with moderate cognitive impairment and significant medical conditions had their medications left unsecured, and staff interviews confirmed that medications were not stored promptly according to policy.
The facility did not complete or maintain required background checks and employment documentation for an administrator, including missing criminal background, EDL, and federal indicator checks, as well as lacking application, license, and reference records. Staff interviews revealed confusion over responsibility for these processes, and the facility's own policies requiring such screenings were not followed.
The facility did not ensure that a qualified and licensed Administrator was on duty, as required by state law. Review of licensing records and staff interviews revealed that the Administrator was not listed as a current Missouri Licensed Administrator, could not provide proof of licensure or renewal, and was not posted as required. This failure had the potential to affect all residents in the facility.
A resident experienced a delay in treatment for a fractured arm due to the facility's failure to ensure follow-up appointments with an orthopedic surgeon. Despite being cognitively intact and independent before the fall, the resident missed several appointments due to transportation issues and lack of communication among staff, leading to increased pain and decreased mobility. The orthopedic surgeon expressed concern over the resident's condition, highlighting the facility's failure to manage appointments and communicate effectively.
A resident with a fractured arm experienced inadequate pain management and missed medical appointments due to facility oversight. The facility failed to conduct timely pain assessments and ensure the resident received necessary medical follow-up, resulting in ongoing pain and mobility issues. Staff interviews revealed a lack of understanding of the electronic medical record system, contributing to poor documentation and communication with the resident's physician.
The facility failed to document medication administration and treatment for three residents over two months. This included missing records for medications and treatments such as Atorvastatin, Citalopram, and catheter care. The residents had conditions like schizophrenia and Alzheimer's, necessitating careful medication management, which was not documented as required.
A long-term care facility failed to control a bed bug infestation, affecting multiple residents. Despite having a prevention and management policy, the facility's efforts were insufficient, as residents continued to report bed bug sightings and bites. Staff confirmed the presence of bed bugs, and the facility had not yet engaged a pest control company, although estimates were obtained. The administrator believed the issue was improving, despite ongoing resident complaints.
A facility failed to report allegations of verbal abuse to the DHSS within the required timeline after two residents reported a CNA verbally abused them. The incident involved a confrontation about smoking outside designated times, where the CNA allegedly used threatening language. Despite residents' complaints and the CNA's admission, the facility administration was not informed in a timely manner, and the CNA returned to work without immediate corrective action.
A facility failed to thoroughly investigate an allegation of verbal abuse by a CNA towards residents during a smoking policy dispute. The CNA allegedly used threatening language, but the investigation was incomplete, lacking interviews and documentation. Despite the incident, the CNA returned to work the next day, raising concerns about resident safety and compliance with regulations.
A resident's care plan was not updated after a fall resulted in a fractured arm, leading to increased need for assistance with ADLs. Despite the resident's decline in functional abilities, the care plan continued to reflect prior independence, leaving staff without necessary guidance. Facility staff acknowledged the oversight, highlighting a gap in managing changes in residents' conditions.
A resident experienced a significant weight loss of 20 pounds over six weeks due to the facility's failure to provide prescribed health shakes three times a day. Despite recommendations from the RD, staff did not include the supplements on meal trays, and the resident's dietary needs were not adequately monitored. Interviews with staff revealed a lack of communication and adherence to dietary orders, contributing to the resident's nutritional decline.
The facility failed to maintain cleanliness and proper food preparation practices in the kitchen. Raw chicken was placed in a sink next to where dishes were being cleaned, leading to potential cross-contamination. The kitchen had accumulated debris, dust on fans and light fixtures, and a white powder spill on the dry storage rack. Staff interviews confirmed expectations for cleanliness and separation of food prep from dishwashing, but these were not met.
The facility failed to ensure accurate and consistent documentation of advanced directives for residents, with discrepancies noted between signed code status forms and physician orders. A resident's advanced directive did not match between the paper chart and the POS, and another resident lacked a current physician's order for code status. Additionally, annual reviews of advanced directives were not conducted for several residents, leading to outdated documentation. Staff interviews revealed inconsistencies in the process of obtaining and documenting code status orders.
The facility failed to ensure complete and accurate documentation of medication administration for several residents, as required by their policy. Reviews of MARs revealed missing documentation for various medications across multiple residents, with no supporting documentation provided. Interviews confirmed that the facility's procedures for transcribing orders and documenting missed medications were not followed.
The facility failed to assess and authorize two residents for self-administration of medications, leaving medications at their bedside without proper orders. Additionally, a resident was not adequately supervised during medication administration, receiving medications from a CMT and taking them unsupervised. Staff interviews confirmed the need for physician orders and assessments for self-administration, highlighting a breach in protocol.
A resident with cognitive intactness and several medical conditions experienced a deficiency in their living environment due to a malfunctioning hot water faucet in their bathroom. Despite informing staff, the issue was not addressed as the facility's maintenance reporting system was not utilized, leaving the resident without access to hot water.
A facility failed to involve a resident's legal guardian in discharge planning, despite the resident's expressed interest in transitioning to a lower level of care. The resident, who was cognitively intact and independent in most activities, had not been involved in discharge discussions. Facility staff faced difficulties contacting the legal guardian, who had not participated in care plan meetings. The resident's psychiatrist deemed them stable, but the evaluation for independent living was ongoing. The facility did not document attempts to communicate with the guardian regarding discharge planning.
The facility failed to provide adequate personal care and hygiene for several residents, including those with severe cognitive impairments and self-care deficits. Observations showed residents with long facial hair, unclean nails, and wearing the same soiled clothing over multiple days. Despite care plans indicating the need for assistance, staff did not consistently provide necessary hygiene care, as confirmed by interviews with CNAs, a CMT, an LPN, and the DON.
The facility failed to conduct and document neurological assessments for two residents after falls, contrary to policy. One resident, with moderate cognitive impairment, was found on the floor twice, once with a cheek bruise, but no neurological checks were documented. Another resident suffered a head laceration from a fall, yet no assessments were recorded. Additionally, the medication cart was left unlocked and unattended, accessible to residents and others, violating the facility's security policy.
A resident with multiple diagnoses, including high blood pressure and edema, was not administered the prescribed dose of Lasix for over two weeks due to a failure in transcribing the medication order to the MAR. Interviews with staff revealed that the process for transcribing orders was not followed, resulting in the omission of the medication and blood pressure monitoring.
Failure to Identify and Monitor Behavioral Health Needs Related to Substance Use
Penalty
Summary
The facility failed to identify, assess, monitor, and address behavioral health needs related to substance use disorder for residents with known histories of substance abuse. The report states that the facility did not thoroughly review referral information that identified recent substance use and positive toxicology results, and it did not implement appropriate behavioral health interventions, monitoring, and services during a period when social services staff were unavailable. As a result, warning signs of relapse and ongoing substance use were not identified or addressed for Residents #104, #105, and #101. Resident #104 had a hospital history that included opioid withdrawal, fentanyl use disorder, and polysubstance use disorder. The resident’s psychosocial history listed substance abuse, increased anxiety, and a past history of suicidal ideations/attempts. The care plan identified risk for polysubstance abuse and overdose, with interventions to monitor for substance abuse, intoxication, withdrawal, and items brought into the facility. Progress notes described erratic behavior, signs of withdrawal, repeated sliding out of a wheelchair, and self-picking that caused a sore on the face. Staff documented that the resident refused clinical evaluation and a telehealth visit, and the physician was notified of behavior and refusal of care, but the notes did not show staff spoke with the physician specifically about withdrawal from illegal substances. Interviews showed staff believed the resident was withdrawing from street drugs, had a history of opioid abuse, and was later found with fentanyl, methamphetamine, and other substances in the resident’s purse and room. Resident #105 had diagnoses including other psychoactive substance abuse and homelessness. The resident experienced an acute change in condition and was found slumped over in a wheelchair, unresponsive, with labored and irregular respirations and oxygen saturation of 82% on 5 liters of oxygen. Narcan was administered twice, CPR was initiated, EMS transported the resident to the hospital, and the resident was later documented as being on a Narcan drip. The record also showed a care plan addressing overdose risk, substance-seeking behavior, monitoring for intoxication and withdrawal, and room checks. The report further described that Resident #104 and Resident #105 spent time together before the overdose event, and police later reported that Resident #104 admitted obtaining narcotics from an outside source and that narcotics were found in the resident’s room and purse.
Dirty resident areas and common spaces
Penalty
Summary
The facility failed to ensure resident rooms, resident common area meeting spaces, and resident belongings were kept in a clean, safe, and homelike manner. Surveyors observed concerns in Resident #2’s room, the shower rooms on the 300, 500, and 100 halls, the resident phone room, and the sunrooms at the ends of resident halls. The facility’s policies stated that resident living areas should be clean, sanitary, comfortable, and maintained in a homelike environment, with daily cleaning of resident areas and shower rooms. Resident #2’s quarterly MDS dated 2/11/26 showed the resident was cognitively intact, had no rejection in care, required partial to moderate assistance with personal hygiene and bathing, and had diagnoses including schizophrenia, infection of the intravertebral disc, malnutrition, and viral hepatitis. On multiple observations, the resident was lying in bed while the fitted sheet had stains and dark discoloration. The room floor next to the bed had multiple empty soda bottles, crumbs of food, food wrappers, and cups containing undigested food. The resident stated the room may not be cleaned every day, said pain made it difficult to pick things up, and reported difficulty swallowing, which led to spitting food and saliva into cups. The 300 hall tub washroom had two large industrial trash cans filled with waste, broken baseboard pieces, and broken tiles behind the toilet. The 500 hall shower room had three large industrial trash cans blocking access to the sink and cabinets, and a soiled sock was observed in the bathtub. The 100 hall shower room had a mildew-like smell, dirty towels, wet towels, hair on the floor and shower wall, and a used washcloth on the floor during repeated observations. The 300 hall resident phone room had a dark sticky stain in the center of the floor and plastic trash in the corner. The 300 East sunroom had an empty wood pallet propped against the wall, and the 100 hall sunroom had a dead cockroach, trash debris, cigarette ash, food wrappers, and a dusty desk. Staff interviews stated resident rooms and shower rooms were cleaned daily and as needed, and the Administrator stated rooms should be cleaned daily, sheets changed when visibly soiled, and inventory lists completed on admission and when new items were brought in.
Failure to Provide ADL Assistance With Bathing, Foot Care, and Meals
Penalty
Summary
The facility failed to provide appropriate ADL care for multiple residents who required assistance with bathing, grooming, foot care, and eating. The facility’s ADL policy stated that residents unable to perform ADLs would receive necessary services to maintain nutrition, grooming, and personal and oral hygiene, and the podiatry policy stated that foot care and toenail clipping would be provided by trained staff or referred to a podiatrist when needed. Despite these policies, surveyors found that residents did not consistently receive showers, some bathing documentation was incomplete or absent, and one resident did not receive needed assistance during meals. One resident with a history of CVA, paraplegia, malnutrition, depression, schizophrenia, and asthma was assessed as dependent for bathing, dressing, toileting, oral hygiene, and personal hygiene, and required maximum assistance with ADLs. The care plan directed staff to provide max assist with ADLs and showers twice weekly. However, shower records showed missing or undocumented bathing on multiple dates, and the resident told surveyors showers were not frequent, that staff had told him/her no because of staffing or equipment issues, and that prior "bed baths" were only wipes without water. The resident’s hair appeared matted with a large amount of dandruff, and the resident reported an itchy scalp and not remembering the last shower. Staff interviews conflicted with the resident’s account, and the Administrator stated the resident had not received a shower since 5/6/26. Another resident with moderate cognitive impairment, chronic lung disease, heart failure, morbid obesity, and difficulty walking required partial to moderate assistance with bathing and personal hygiene and supervision or touch assistance with footwear. The resident reported needing help entering the shower room because of a lip at the entrance and said the shower room was filthy and lacked shower shoes. Surveyors observed extremely dry legs and feet, dark discoloration on the calves, oily hair, and toenails about one-half inch long and jagged. The resident said no staff had provided toenail trimming or foot care since admission. The shower room on the 200 hall had used wet towels, a moldy odor, and mold on the tile grout. Shower sheets were signed but did not describe the type of bathing or note skin or foot issues, and the resident was not listed on the facility’s podiatry list. A third resident with schizophrenia, infection of the intervertebral disc, malnutrition, and viral hepatitis required partial to moderate assistance with bathing and supervision or touch assistance with footwear. Shower sheets were signed, but they did not describe the bathing provided. The resident told surveyors he/she no longer took showers because the shower room was filthy and there were no shower shoes, and said he/she could not remember the last shower received at the facility. During meal observation, another resident with hypertension, depression, and anxiety who required supervision or touch assistance with eating struggled to open a milk carton and had visible hand shaking while trying to eat. The resident used his/her hands to move food and had difficulty lifting utensils and toast to the mouth. Staff were present in the dining room but did not assist, and the resident said tablemates often helped with opening cartons.
Failure to Monitor and Respond to Substance Use and Overdose
Penalty
Summary
The facility failed to provide necessary care and services for two residents by not adequately assessing, monitoring, and responding to signs and symptoms associated with substance use and overdose. One resident, who had diagnoses including opioid abuse, acute kidney failure, and COPD, had a urine drug screen ordered and later tested positive for methamphetamine. After returning from the store and taking nighttime medication, the resident was found sitting upright in a wheelchair, snoring loudly, and required sternum rub and Narcan administration. The resident was then moved to bed, gasped after Narcan, and was later documented as being back in the wheelchair eating a sandwich. The physician stated he expected 24 hours of neurological checks and vital signs to be obtained and documented, but the record contained no documentation of monitoring after the overdose. Staff interviews confirmed that no additional monitoring was put in place after the overdose beyond the brief note that the resident was eating a sandwich. The DON, ADON, and regional nurse consultant acknowledged that monitoring should have been documented and that vital signs and cognitive status should have been recorded. The physician said he had ordered monitoring, a urine drug screen, and psychiatric consultation after being notified of the overdose, and he would have expected neurological checks and documentation in the medical record. An LPN stated that if a resident had a drug overdose and Narcan was administered, emergency services should have been called, and that the documentation provided was not appropriate monitoring. The facility also failed to assess, evaluate, and implement interventions for another resident who showed behavioral changes and signs consistent with substance use or withdrawal. That resident had a history of substance abuse, suicidal ideation, self-injurious behavior, and multiple opioid-related medication orders, including hydromorphone, hydrocodone-acetaminophen, and Narcan. Progress notes described erratic behavior, repeated sliding out of the wheelchair, self-picking that caused a sore on the face, and refusal of clinical evaluation and telehealth assessment. Staff documented concern for withdrawal and suspected drug use, but the record showed no further assessment or documentation of withdrawal symptoms after those notes. Additional notes and interviews showed the resident later admitted recent fentanyl and methamphetamine use, refused a room sweep, became aggressive, and demanded to sign an AMA form. A search of the resident’s purse found capsules, a crystallized substance, and white powder that the resident identified as fentanyl and methamphetamine. Police were notified, narcotics were seized, and the resident was taken into custody on drug trafficking charges. Staff and the physician described the resident as having erratic behavior, possible withdrawal, and drug-seeking behavior, but the record did not show ongoing assessment or documentation of the withdrawal-related symptoms that had been observed.
Failure to Provide Required RN Coverage Seven Days a Week
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by their own policy and federal regulations. Review of daily staffing sheets revealed that there were multiple days when no RN was scheduled, specifically from 8/20 through 8/22, 8/25 through 8/31, and 9/1 through 9/5. During an interview, the Director of Nursing (DON) acknowledged that only two RNs were employed in the building and admitted to working as both the DON and the floor RN, not realizing that these roles could not be fulfilled simultaneously. The facility census at the time was 86 residents, and the deficiency had the potential to affect all residents.
Failure to Follow Pureed Diet Recipes During Meal Preparation
Penalty
Summary
During an observed mealtime preparation, a staff member in the kitchen failed to follow the facility's recipe for preparing pureed breaded chicken breast. Instead of using the specified amount of water and chicken base to create a broth as outlined in the recipe, the staff member added only approximately one tablespoon of water to the chicken breast and blended it. The resulting mixture was of ground meat consistency and not smooth, as required for pureed diets. The staff member acknowledged not following the recipe as written, despite having reviewed it. Additionally, the same staff member prepared pureed mixed vegetables by blending them until smooth, but the final product contained small lumps. The Dietary Manager confirmed that there was no recipe for pureed mixed vegetables and that cooks were expected to follow recipes to ensure proper nutrition. The Dietary Manager and the Administrator both acknowledged the expectation that recipes be followed and were unsure why this did not occur.
Failure to Maintain Kitchen Cleanliness Due to Inadequate Staffing and Cleaning Practices
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen, as evidenced by observations of built-up dirt, grease, and grime on the floors and walls in multiple areas, including under the refrigerator, stove, fryer, coffee station, and behind the sinks. The facility's dietary cleaning duties required both morning and evening crews to wipe down all stainless surfaces, clean ovens and stove tops, and mop the kitchen and dining room, with the cook on duty responsible for checking completion before clocking out and the manager ensuring the process was followed. However, during interviews, the Dietary Manager stated that dietary staff were not allowed overtime, resulting in inadequate cleaning, and confirmed that the department did not have sufficient labor hours for deep cleaning. The Administrator acknowledged awareness of the kitchen cleanliness concerns.
Failure to Schedule and Document Urgent Urology Appointment
Penalty
Summary
Facility staff failed to follow professional standards and the facility's own policy regarding the transcription and execution of physician orders for a resident with a diagnosis of prostate cancer. After a urologist contacted the facility and requested an urgent appointment for the resident, staff documented the need for an appointment and prepared transportation paperwork, but did not actually schedule the appointment. When a Certified Nurse Aide escorted the resident to the urologist's office, they were turned away because no appointment had been made. The CNA reported the incident to the charge nurse, but there was no documentation of any follow-up or rescheduling of the appointment in the resident's medical record. Interviews with staff revealed that the responsibility for making and documenting the appointment was unclear, with some staff believing the Director of Nursing and Administrator would handle the situation. The resident, who had moderate cognitive impairment and a history of prostate surgery, was unaware of any scheduled appointment and did not recall attending one. The facility's policy required that physician orders be transcribed, appointments scheduled, and all actions documented in the medical record, but these steps were not completed, resulting in a delay in the resident receiving necessary follow-up care.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details about the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Improper Storage of Medications in Unsecured Areas
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were stored in accordance with professional standards and facility policy. Multiple observations revealed that boxes containing medication cards, some labeled with residents' names and containing various prescription drugs, were left in open and accessible areas behind the nurse's station on the second floor. These areas were not secured, lacked doors, and allowed anyone to access the medications. Additionally, finished medication cards, some still containing medications, were found in trash bags and open boxes behind the nurse's station. The medications observed included antihypertensives, diabetic medications, and antihistamines, all of which were not properly secured as required. Interviews with staff confirmed that medications delivered by the pharmacy were routinely left behind the nurse's station, sometimes for several days, instead of being immediately stored in locked compartments as per facility policy. Staff acknowledged that medications should be put away promptly or locked in the storage room if immediate storage was not possible. The Regional Nurse Advisor and facility administration also confirmed that the observed medications had been delivered several days prior and had not been stored properly. Two residents with moderate cognitive impairment and significant medical diagnoses were specifically identified as having their medications left unsecured.
Failure to Conduct Required Background Checks and Maintain Employment Records for Administrator
Penalty
Summary
The facility failed to conduct required background screenings and maintain necessary employment documentation for one hired employee, identified as Administrator A. Specifically, there was no evidence of a Criminal Background Check (CBC), Employee Disqualification List (EDL) check, or federal indicator check for Administrator A. Additionally, the facility did not have records of Administrator A's employment application, resume, experience, education, references, or license verification, as required by state regulations. Administrator A was employed at the facility for approximately four months, during which time these deficiencies persisted. Interviews with facility staff revealed confusion and lack of clarity regarding who was responsible for completing and maintaining Administrator A's employment file and background checks. The Regional Human Resources (HR) representative stated that Administrator A was already employed when they returned to the company and assumed that the necessary documentation would be transferred from another facility within the same company. However, neither the HR representative nor the Business Office Manager (BOM) could locate or confirm the existence of Administrator A's employment file or background screening results. The BOM also could not recall any specific discussions about missing documentation. The facility's policies on abuse, neglect, and background screening explicitly require thorough background investigations and prohibit the employment of individuals with a history of abuse, neglect, or related offenses. Despite these policies, the facility did not follow its own procedures in the case of Administrator A, resulting in a lack of compliance with both internal policy and state regulations. This failure had the potential to affect all residents in the facility, which had a census of 86 at the time.
Failure to Maintain a Licensed Administrator on Duty
Penalty
Summary
The facility failed to ensure that a qualified and licensed Administrator was on duty, as required by state law. Review of the Missouri Board of Nursing Home Administrators (MBNHA) license registry showed that Administrator A was not listed as a current licensed Administrator in Missouri. Administrator A was unable to provide proof of a valid administrator's license or evidence of renewal, and was not listed on the Health Services Executive (HSE) license registry. Corporate and facility staff, including the Regional Director of Operations and Regional HR, confirmed that Administrator A's license status was not verified at the time of employment, and there was no documentation of a completed background check or onboarding process for Administrator A. The Director of Nursing noted that the administrator's license was not posted as required, and Administrator A claimed it was unnecessary. The lack of a qualified Administrator on duty had the potential to affect all residents in the facility, which had a census of 86 at the time of the survey. The deficiency was identified through interviews and record reviews, which revealed gaps in the facility's process for verifying and maintaining required licensure for upper management positions, specifically the Administrator role.
Failure to Ensure Resident's Orthopedic Follow-Up
Penalty
Summary
The facility failed to ensure that a resident kept all necessary appointments with an orthopedic surgeon following an unwitnessed fall that resulted in a fracture of the right arm. The resident, who was cognitively intact and independent with activities of daily living prior to the fall, experienced significant pain and a decrease in their ability to perform daily activities due to the delay in treatment. The facility's policy required nursing staff to assist with scheduling appointments and coordinating transportation, but this was not effectively executed, leading to missed appointments and delayed surgical intervention. The resident's medical records indicated that after the fall, they were sent to the emergency room and returned with a splint and instructions to follow up with an orthopedic specialist. Despite these instructions, the resident missed several appointments due to issues with transportation and lack of communication between the facility staff and the orthopedic office. The resident's condition worsened, with increased pain, swelling, and bruising, yet there was no documentation of rescheduling missed appointments or notifying the physician of the resident's ongoing issues. Interviews with facility staff revealed a breakdown in communication and responsibility. The SSD was unaware of missed appointments, and the charge nurse failed to reschedule the surgery or inform the SSD to arrange transportation. The orthopedic surgeon expressed concern over the resident's pain and the potential for permanent loss of mobility due to the delay in surgical intervention. The facility's failure to manage the resident's appointments and communicate effectively with healthcare providers resulted in prolonged pain and decreased quality of life for the resident.
Failure in Pain Management and Timely Medical Follow-Up
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who suffered a fall resulting in a fractured arm. The resident missed a scheduled surgery due to being fed by staff, which led to the surgery being canceled. Despite several attempts by the orthopedic physician's office to set up appointments, the facility did not ensure the resident was seen by the orthopedic physician or reschedule the surgery. Additionally, the facility did not complete a new pain assessment after the resident's arm was fractured, resulting in ongoing pain and loss of mobility for the resident. The facility's Pain Management policy outlines a systematic approach for recognizing, assessing, and monitoring pain, which was not followed in this case. The resident's electronic Medication Administration Record (eMAR) and Treatment Administration Record (eTAR) showed a lack of documentation for pain assessments and administration of prescribed pain medications. The resident's progress notes indicated that the resident experienced significant pain and swelling, yet there was no consistent documentation or follow-up on pain management. Interviews with facility staff revealed a lack of understanding and implementation of the electronic medical record system, leading to inadequate documentation of pain assessments and medication administration. The facility's failure to notify the resident's physician about missed appointments and ongoing pain further contributed to the deficiency. The resident continued to experience pain and swelling, with no effective pain management plan in place, highlighting the facility's failure to adhere to its own pain management policy.
Failure to Document Medication Administration and Treatment
Penalty
Summary
The facility failed to maintain proper documentation of medication administration and treatment for three residents over a period of two months. This deficiency was identified through interviews and record reviews, which revealed that the staff did not document the administration of various medications and treatments as required by the facility's Medication Administration policy. The policy mandates that medications be administered by licensed nurses or authorized staff, following the six rights of medication administration, and that documentation be completed immediately after administration. For Resident #11, there was a lack of documentation for multiple medications, including Atorvastatin, Citalopram, Ferrous Sulfate, Melatonin, and others, from October 1 through December 31. Additionally, there was no documentation of catheter care, pain assessments, or monitoring for side effects of anticoagulant and antipsychotic medications. Resident #11's medical history included schizophrenia, diabetes, and chronic kidney disease, among other conditions, which necessitated careful monitoring and medication management. Resident #12 also experienced a lack of documentation for medications such as Alendronate, Aspirin, Calcium-Vitamin D3, and Donepezil from October 1 through December 18. There was no record of pain assessments or monitoring for side effects of anti-anxiety and antipsychotic medications. Resident #12 had diagnoses including Alzheimer's disease and heart disease, requiring consistent medication administration. Similarly, Resident #10's records showed no documentation for medications like Atorvastatin, Ingrezza, Lisinopril, and others from October 1 through November 30. The resident's conditions, including schizophrenia and bipolar disorder, required regular medication and monitoring, which were not documented as per the facility's policy.
Bed Bug Infestation in LTC Facility
Penalty
Summary
The facility failed to maintain effective pest control, resulting in a bed bug infestation affecting multiple resident rooms. Observations and interviews revealed that residents were experiencing bed bug bites, and live bed bugs were found in various locations, including mattress seams and folded linen. The facility's Bed Bug Prevention and Management Policy outlined measures for prevention, eradication, and containment, but these measures were not effectively implemented, as evidenced by the ongoing presence of bed bugs in the facility. Residents reported seeing bed bugs in their rooms and on their belongings, with some residents experiencing bites and finding bed bugs in their personal spaces. Interviews with staff, including housekeepers and CNAs, confirmed the presence of bed bugs throughout the facility. Despite efforts to treat affected areas with diatomaceous earth and bed bug spray, the infestation persisted, and residents continued to report sightings and bites. The facility's maintenance director acknowledged the use of safe treatment methods but did not treat adjacent rooms unless bed bugs were reported there. The administrator was aware of the bed bug issue but believed the problem was improving, despite ongoing complaints from residents. The facility had not yet hired a pest control company, although estimates for treatment had been obtained. The failure to effectively manage the bed bug infestation had the potential to affect all residents in the facility.
Failure to Report Verbal Abuse Allegations
Penalty
Summary
The facility failed to report allegations of verbal abuse to the Department of Health and Senior Services (DHSS) within the required timeline after two residents reported a staff member verbally abused them. The incident involved a Certified Nursing Assistant (CNA) who allegedly used threatening language towards residents during a confrontation about smoking outside of designated times. Despite the residents' complaints and the CNA's admission of using inappropriate language, the facility administration was not informed of the verbal abuse allegations in a timely manner. Resident #1, who has a history of major depressive disorder and bipolar disorder, reported feeling threatened by the CNA's aggressive stance and language. The resident attempted to report the incident to facility administration but was upset to see the CNA back at work the following day. Resident #2, who has a history of stroke and anxiety, also felt threatened during the incident and expressed frustration with the smoking policy. Despite these reports, the facility staff, including the Maintenance Director and LPN, did not report the allegations of verbal abuse to the appropriate authorities. The facility's failure to report the allegations of verbal abuse was compounded by a lack of communication and understanding among staff members about their responsibilities in such situations. The Director of Nursing (DON) and Administrator were not made aware of the verbal abuse allegations until informed by a surveyor, and the CNA was allowed to return to work without any immediate corrective action. This lack of timely reporting and response to the allegations of abuse highlights a deficiency in the facility's adherence to its own policies and procedures for handling such incidents.
Inadequate Investigation of Verbal Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of verbal abuse involving a Certified Nursing Assistant (CNA) and several residents. The incident occurred when a CNA allegedly cursed and threatened a resident after a confrontation about smoking outside of designated times. The resident reported feeling threatened by the CNA's aggressive stance and language. Despite the resident's complaint, the facility did not adequately interview all involved parties or document verbal statements, and the CNA was allowed to return to work the following day. The facility's abuse and neglect policy requires immediate reporting and thorough investigation of all allegations of abuse, including verbal abuse. However, the investigation was incomplete, as not all staff and residents involved were interviewed, and there was a lack of documentation of the incident in the residents' progress notes. The Maintenance Director and other staff members provided inconsistent accounts of the incident, and the CNA admitted to using inappropriate language, but this was not reflected in the written statements provided to the administration. The facility's failure to follow its own policy and procedures for investigating allegations of abuse resulted in an inconclusive determination of whether verbal abuse occurred. The lack of proper documentation and communication among staff members hindered the investigation process, and the CNA's return to work without proper resolution of the allegations raised concerns about resident safety and the facility's compliance with federal regulations.
Failure to Update Care Plan After Resident's Fall
Penalty
Summary
The facility failed to ensure that a resident's care plan was updated and accurate to reflect the resident's increased need for assistance with activities of daily living (ADLs) following a fall that resulted in a fractured arm. The resident, who was previously independent in performing ADLs, required additional staff assistance after the incident. However, the care plan did not document these changes, leaving staff without the necessary guidance to provide appropriate care. The resident's medical records indicated a significant decline in functional abilities after the fall, necessitating increased assistance with transferring, dressing, toileting, and showering. Despite these changes, the care plan continued to reflect the resident's prior level of independence, failing to incorporate the new requirements for staff assistance. Interviews with facility staff, including the MDS Coordinator and the Interim Director of Nursing, confirmed that the care plan should have been updated to reflect the resident's new needs. The lack of an updated care plan resulted in a deficiency, as it did not provide staff with the necessary information to care for the resident effectively. The resident's physician's office representative also noted that the resident would not be independent with ADLs due to the fractured arm and the use of a sling, emphasizing the need for an updated care plan. The failure to update the care plan was acknowledged by the facility's staff, highlighting a gap in the facility's processes for managing changes in residents' conditions.
Failure to Provide Nutritional Supplements Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status, resulting in a significant weight loss of 20 pounds over six weeks. The resident, who had moderate cognitive impairment and required partial assistance with meals, was supposed to receive health shakes three times a day as recommended by the Registered Dietician (RD). However, staff did not provide these supplements as ordered, contributing to the resident's weight loss. Observations and interviews revealed that the resident's meal trays often lacked the prescribed health shakes, and staff did not offer alternatives when the resident refused the served food. The resident expressed a lack of appetite and was not provided with the necessary assistance to consume meals, such as cutting food. The facility's policy required staff to monitor and document dietary intake and notify the physician of significant weight changes, but these procedures were not adequately followed. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), indicated a lack of communication and adherence to dietary orders. The meal tickets did not reflect the required supplements, and staff failed to ensure the resident received the necessary nutritional support. The Director of Nursing (DON) and the Administrator acknowledged the oversight in providing the health shakes and the resident's weight loss, highlighting a breakdown in the facility's processes for managing and monitoring nutritional interventions.
Deficiencies in Kitchen Cleanliness and Food Preparation Practices
Penalty
Summary
The facility failed to maintain proper food preparation and cleanliness standards in the kitchen and related areas. During lunch preparation, the Dietary Supervisor was observed placing raw chicken in a sink while another staff member cleaned dishes in an adjacent sink, resulting in water splashing onto the raw chicken. This indicates a failure to separate food preparation from dish cleaning, which is essential to prevent cross-contamination. Additionally, the facility's dietary cleaning duties were not adequately followed, as evidenced by the accumulation of debris and substances on the floors, baseboards, and walls in various kitchen areas, including under the sink, cereal/toaster station, and around the oven and deep fryer. Further observations revealed that the dishwashing room had fans covered with thick dust, which were positioned to blow on clean dishes, and the light fixture above the food preparation table had significant dust buildup. The dry storage rack was also found with a white powder spill in various areas. Interviews with kitchen staff, the Dietary Supervisor, and the Administrator confirmed that all kitchen staff were responsible for cleaning duties and that food should be prepared away from dishwashing areas. However, the observed conditions indicated a lack of adherence to these expectations, resulting in unsanitary conditions and potential contamination risks.
Inconsistent Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that the advanced directives of residents were accurately documented and consistently updated. Specifically, Resident #7's advanced directive did not match between the paper chart and the physician's orders sheet (POS), with discrepancies noted between a signed Do Not Resuscitate (DNR) form and a Full Code status listed in the physician orders. Additionally, Resident #72 did not have a current physician's order for code status, despite having a signed form indicating full resuscitation. The facility also did not conduct annual reviews of advanced directives for several residents, including Residents #62, #25, #2, #19, #26, and #41. Observations revealed that outdated code status forms were being replaced with updated ones by the social worker, indicating a lapse in timely updates. Interviews with staff, including Licensed Practical Nurses (LPNs) and the Director of Nursing (DON), highlighted inconsistencies in the process of obtaining and documenting code status orders, with some staff treating all residents as Full Code by default. The social worker was responsible for obtaining code status upon admission and updating it annually, but there were delays in placing updated forms into the medical records. The nursing department was tasked with obtaining physician orders for code status, yet discrepancies persisted between the signed code status sheets and the POS. The DON confirmed that code status should be documented on the face sheet, POS, and in the Activities of Daily Living (ADL) tool, but the process was not consistently followed, leading to the deficiencies noted in the report.
Incomplete Medication Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented, particularly concerning the administration of medications and treatments for five residents. The facility's policy mandates that medications be administered safely, timely, and as prescribed, with documentation by licensed personnel. However, the review of the Medication Administration Records (MAR) for several residents revealed multiple instances where staff failed to document the administration of prescribed medications, with no supporting documentation provided. For Resident #50, the MAR showed missing documentation for the administration of hydralazine, atorvastatin, docusate, and accu-checks over several months. Similarly, Resident #20's MAR indicated missing documentation for medications such as memantine, potassium chloride, Tradjenta, furosemide, Senna Plus, calcium antacid, citalopram, buspirone, amlodipine, and olopatadine solution. Resident #67's records also lacked documentation for simvastatin and vitamin B-12 administration. Resident #7's MAR showed missing documentation for Xifaxan, benztropine, atorvastatin, and mirtazapine. Lastly, Resident #51's records indicated missing documentation for aspirin, Eliquis, atorvastatin, olanzapine, and furosemide. Interviews with the LPN and the Director of Nursing confirmed that the facility's procedures require nurses to transcribe orders correctly and document any missed medications, notifying the doctor and making a note in the resident's chart, which was not adhered to in these cases.
Failure to Assess and Supervise Medication Self-Administration
Penalty
Summary
The facility failed to ensure that residents were properly assessed for self-administration of medications and that physician orders were maintained for such self-administration. This deficiency was observed in two residents who had medications left at their bedside without proper authorization or assessment. Resident #42 had a bottle of Flonase nasal spray at the bedside without any documented assessment or physician order for self-administration. Similarly, Resident #62 had inhalers stored in their room without a current self-administration assessment or physician order, despite using them throughout the day. Additionally, the facility did not adequately supervise Resident #77 during medication administration. The resident, who was new to the facility and not assessed for self-administration, was handed a cup of medications by a Certified Medication Technician and allowed to walk away unsupervised. The resident took the medications at the nurse's station without staff observation, which is against the facility's policy that requires supervision unless a resident has been assessed and authorized to self-administer medications. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the facility's policy requires a physician's order and a completed self-administration assessment before residents can self-administer medications. The staff acknowledged that Resident #77 should have been supervised during medication administration to ensure safety, and that any resident wishing to take medications in a private area should still be supervised. The lack of adherence to these protocols led to the deficiencies observed during the survey.
Failure to Maintain Homelike Environment Due to Malfunctioning Faucet
Penalty
Summary
The facility failed to provide a homelike environment for a resident due to a malfunctioning hot water faucet in the resident's bathroom. The resident, who has diagnoses including depression, Alzheimer's disease, high blood pressure, high cholesterol, and mood disorder, is cognitively intact and can shower independently with only setup assistance needed. The resident expressed a preference for bathing in the sink in their room due to delays in being taken to the shower room and had informed the nursing staff about the issue with the hot water faucet. Despite the resident's report, the facility staff, including a CNA, maintenance personnel, an LPN, and the Administrator, were unaware of the malfunctioning faucet. The facility has a system in place for reporting maintenance issues, involving paper slips and a box on the maintenance door, but this system was not utilized in this instance. The lack of awareness and action from the staff resulted in the resident not having access to a functioning hot water faucet in their bathroom.
Failure to Involve Legal Guardian in Discharge Planning
Penalty
Summary
The facility failed to implement and document a discharge planning process involving the legal guardian for a resident who expressed interest in transitioning to a placement with a lower level of care. The facility's Discharge Summary and Plan policy requires that every resident is evaluated for discharge needs and has an individualized post-discharge plan developed with the assistance of the resident and their family. However, there was no documentation of the legal guardian's involvement in care plan meetings or discharge planning for the resident, who was admitted with a history of major mental illness and had a public administrator appointed as their legal guardian. The resident, who was cognitively intact and independent in most activities of daily living, expressed feeling confined in the facility and had not been involved in any discharge planning discussions. The resident had previously communicated with their legal guardian about the desire to live independently, but no further steps were taken. The facility's Social Worker and Social Services Director acknowledged difficulties in contacting the legal guardian, who had not participated in care plan meetings or communicated about discharge planning. The resident's psychiatrist considered the resident stable, but the evaluation for independent living was ongoing. The facility staff, including the Administrator, reported challenges in reaching the legal guardian, who was a public administrator in another county. The resident had been compliant with medication and exhibited no problematic behaviors, yet the facility had not documented attempts to communicate with the guardian regarding discharge planning. The Administrator was unaware of the lack of documentation by the Social Services Director and expected discharge planning to be discussed and documented during quarterly care plan meetings.
Deficiency in Personal Care and Hygiene for Residents
Penalty
Summary
The facility failed to provide adequate personal care, nail care, and facial hair hygiene for five residents who required assistance with activities of daily living (ADL). Observations and interviews revealed that Resident #2, with severe cognitive impairment and multiple diagnoses, was found with long facial hair, dark debris under fingernails, and wearing stained clothing over consecutive days. Despite being incontinent and requiring full assistance with hygiene, the resident was not properly cleaned during perineal care, leaving feces between the buttocks. Resident #19, also with severe cognitive impairment and paralysis, was observed with long nails and dark debris under fingernails over multiple days, indicating a lack of proper nail care. Similarly, Resident #20, who has Alzheimer's disease and frequently refuses care, was seen wearing soiled clothing and with unkempt nails and hair. Despite the care plan indicating the need for assistance and encouragement for good hygiene, the resident's personal care needs were not adequately addressed. Resident #7, diagnosed with dementia and other conditions, was observed wearing the same stained clothing for three days and had a dark substance under fingernails. Resident #17, who is cognitively intact but requires supervision for hygiene, expressed dissatisfaction with long facial hair, which staff failed to address. Interviews with staff, including CNAs, a CMT, an LPN, and the DON, confirmed that residents should receive assistance with showers, nail cleaning, and facial hair shaving, but these were not consistently provided.
Failure to Conduct Neurological Assessments and Secure Medication Cart
Penalty
Summary
The facility failed to complete and document neurological assessments for two residents who experienced falls. Resident #79, with moderate cognitive impairment and a high fall risk, was found on the floor on two occasions, once with a bruise on the cheek. Despite the facility's policy requiring neurological checks after falls, no such documentation was found in the nurse's notes for these incidents. Similarly, Resident #42, who had no prior fall history, suffered a fall resulting in a head laceration. The resident reported hitting their head and bleeding, yet no neurological assessments were documented post-fall, contrary to the facility's policy. Additionally, the facility did not secure the medication cart on the 200 unit, leaving it unlocked and unattended. Observations noted the cart was left open with the medication administration record binder and keys on top, accessible to residents and others in the vicinity. This was against the facility's policy, which mandates that medication carts be locked when not in use and keys not left unattended. Interviews with staff, including the Director of Nursing and Licensed Practical Nurses, confirmed the expectations for conducting neurological assessments and securing medication carts. However, these protocols were not followed, leading to deficiencies in both resident care and medication security. Staff acknowledged the lapses in securing the medication cart and conducting necessary assessments post-fall.
Failure to Administer Lasix as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a resident was not administered the ordered dose of Lasix, a diuretic, for over two weeks. The resident had multiple diagnoses, including high blood pressure, diabetes, anxiety, high cholesterol, and pain, and had an order for Lasix 20 mg by mouth daily for seven days, with specific instructions to monitor blood pressure and withhold the medication if the blood pressure was below 100/50. However, the medication administration record (MAR) for June 2024 showed no entry for the Lasix or the resident's blood pressure, indicating a failure to administer the medication as prescribed. Interviews with facility staff revealed that the process for transcribing medication orders involved the nurse transcribing the order to the MAR as written or verbally given by the physician. The Licensed Practical Nurse (LPN) stated that for orders with specific time frames or parameters, the nurse would block out the days on the MAR or transcribe the order as written. The Director of Nursing (DON) confirmed that she expected the nurse to transcribe the order as written on the physician's order sheet to the MAR. This deficiency highlights a lapse in the facility's medication administration process, leading to the resident not receiving the necessary medication for their condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Louis Altenheim | 0.3 mi | — | 20 | 0 |
| Magnolia Wellness Center | 1.1 mi | ★★★★★ | 10 | 1 |
| Pine Grove Manor | 2.1 mi | ★★★★★ | 20 | 1 |
| Lansdowne Village | 2.3 mi | ★★★★★ | 18 | 0 |
| Beauvais Rehab And Healthcare Center | 2.8 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.