Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 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.
A resident with esophageal obstruction, gastritis, malnutrition, and a history of a removed G-tube experienced a 20.52% weight loss in three months while remaining on a regular diet with Boost TID. Staff observed the resident appearing gaunt, struggling to swallow, gagging on saliva, and spitting chewed food into a bottle, yet nursing notes did not document intake or swallowing issues and the physician, RD, and ST were not notified of the significant weight loss as expected. The resident was not placed on weekly weights, the care plan was not updated to reflect the diet order, and the RD made no new recommendations at the earlier weight-loss review.
Food storage, dish sanitizing, and kitchen cleaning were not maintained according to professional standards. Surveyors observed uncovered and undated food, debris and pests in food areas, dented cans, wet and dirty items stored with food, and boxes stored under a fuse panel. Staff could not properly test the dish machine or 3-sink sanitizer, there was no test log, and the Dietary Mgr and ADM acknowledged problems with sanitizer use and monitoring. An air gap was also missing at the ice machine drain.
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.
The facility failed to consistently send transfer and discharge notices to the Ombudsman for multiple resident discharges. The Ombudsman reported not receiving the notifications consistently, the SSD said he had not sent the documentation and was unsure what the prior SSD had done, and the Administrator said she expected the SSD to handle the required notices. The facility also had not had a dependable SSD for several months.
Lack of individualized and evening activity programming: The facility did not provide an ongoing activity program that matched residents’ interests and choices, and it did not provide 1:1 activities for a resident identified as needing them. Residents reported no evening activities, repeated programming, limited variety, and little staff encouragement to participate. One resident with multiple chronic conditions and another with cognitive impairment wanted more meaningful activities, while a cognitively intact resident with CVA, paraplegia, and depression said staff did not regularly offer time out of bed or room-based engagement. The AD stated she did not have a 1:1 list, and the calendar showed no evening activities.
Incomplete smoking assessments and unsecured smoking materials were found for three residents. One resident with cancer, chronic lung disease, seizures, and stroke was observed smoking outside and then entering the building with a lighter still in hand and taking it to the room. Another resident with schizophrenia, malnutrition, and other diagnoses was found in bed with a half-smoked cigarette and a lighter beside the bed. A third resident with COPD, diabetes, and mild intellectual disabilities had an incomplete smoking evaluation and a care plan identifying the resident as a smoker, while staff observed the resident returning from the smoking patio under supervision.
Failure to Complete Employee TB Testing: The facility failed to ensure required two-step TB skin testing was completed for 9 of 10 sampled employees. Record review showed several employee files lacked documentation of either the first or second step TB test, while others had only a first step test documented with no second step recorded. The Administrator and Regional Nurse Consultant stated staff should receive the first step TB test before starting on site and the second step within the required timeline, and nursing staff was responsible for administering the tests.
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.
Failure to provide NOMNCs to three residents when Medicare Part A skilled services ended. The facility policy required the CMS-10123 notice to be issued when covered services were ending, including when a resident remained in the facility, and at least 2 days before the end of the covered stay. Record review showed three residents stayed in the facility after Part A services ended, but no NOMNC forms were found; the Administrator said the notices should have been given and noted the facility had been without a social worker for several months.
Expired medications and biologicals were found in two medication rooms and one treatment cart, including expired nutrition formula, laxatives, vitamins, Acamprosate, Atorvastatin, and Mucinex-DM. Staff interviews showed no single person was responsible for auditing medication rooms and carts, and the DON, ADON, and Regional Nurse Consultant stated the facility relied on a monthly pharmacy partner audit while staff were expected to remove expired items when noted.
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.
Failure to address weight loss and swallowing difficulty
Penalty
Summary
The facility failed to identify and address a resident’s nutritional needs and swallowing difficulties, resulting in a significant weight loss of 20.52% in three months. The resident had diagnoses including schizophrenia, malnutrition, viral hepatitis, esophageal obstruction, gastritis, nausea with vomiting, and alcoholism. The resident’s record also showed a history of a G-tube that had been removed, and speech therapy had previously recommended thin liquids and regular solid food. Despite these findings, the resident’s care plan was not updated to reflect the upgraded diet order, and the resident remained on a regular diet with Boost three times daily. The resident’s weight changed from 143.8 pounds to 155 pounds, then dropped to 141 pounds and later to 128.7 pounds, with no weight documented when the resident returned from therapeutic leave. The resident was not placed on weekly weights as required by facility policy for residents with weight loss, and the e-POS showed only monthly weights. Nursing progress notes did not document the resident’s meal intake, supplement consumption, swallowing difficulties, or hypersalivation, and there was no documentation that the physician was notified of the weight loss on the dates when the resident’s weight declined. The RD documented the weight loss but made no new recommendations at the earlier visit, and the physician progress note did not address the weight loss when the resident’s weight was 128.7 pounds. During observation, the resident appeared extremely gaunt, with loose clothing and a sunken face, and there were empty Boost bottles and cups containing undigested food and saliva near the bed. The resident stated he or she was weak, had difficulty swallowing, had to chew food very finely to get it down, and frequently gagged on saliva. The resident also said he or she had told staff about the swallowing problems and believed a softer texture diet was needed again. Later observation showed the resident eating a regular-texture hamburger, chewing it repeatedly, and spitting it into a bottle because it would not go down, with no staff present to assist. Staff interviews confirmed that multiple staff were aware of the resident’s swallowing problems and poor intake, but the physician, RD, and speech therapy were not notified as expected, and the DON was not aware of the resident’s recent significant weight loss.
Food Storage and Dish Sanitizing Deficiencies
Penalty
Summary
The facility failed to ensure food storage, dishwasher sanitizing, and cleaning were performed in accordance with professional standards of practice. Surveyors observed multiple sanitation and storage problems in the kitchen, dining room, and storage room, including food left uncovered or open to air, food items without dates, wet or dirty items stored with food, debris on floors and under equipment, and dented cans in storage. The report also noted that there was no air gap between the ice machine and the drain in the kitchen. In the dining room, surveyors repeatedly observed a dead cockroach on the floor near the stairwell door on multiple days. In the kitchen, observations included sliced cheese open to air, sliced onions with plastic pulled back, an uncovered container of vanilla pudding, wrapped ground beef without a date, dirt and debris under the prep area, a dead bug on the floor, salt packets on the floor, crumbs and debris behind the prep table, an uncovered package of cheese slices, milk cartons with conflicting dates, water dripping from a refrigerator light bulb onto a box of milk, ground beef dated 5/15 that appeared darker on one side, and an opened bag of frozen cauliflower tied in a knot without a date. In the storage room, surveyors observed empty boxes on the floor, sugar packets on the floor, dust and debris around the perimeter and under shelves, broken-down boxes stored on shelves among canned goods, dented cans, plastic gloves on shelves and the floor, sticky floors, food crumbs inside a steam table, boxes stored under an electrical/fuse panel despite posted signs, a partially open 25-pound bag of seasoned fish breading, and visibly soiled towels stored with unopened tortilla chips. The dish machine and three-sink sanitizer were also not being monitored as required: one dietary aide said he/she did not know how to test the dish machine and was soaking dishes in brown water, another aide was unable to properly verify sanitizer concentration, and the Dietary Manager stated there was no test log and that the dish machine had not been used since she started in March 2026. The Dietary Manager and Administrator also acknowledged issues with sanitizer testing, use of bleach for soaking utensils, and the lack of regular testing records.
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 Send Transfer and Discharge Notices to Ombudsman
Penalty
Summary
The facility failed to send copies of transfer and discharge notices to a representative of the Office of the State Long-Term Care Ombudsman for residents discharged in January, February, March, and April 2026. The facility policy, last revised 4/28/25, required that a copy of the discharge or transfer notice be sent to the Ombudsman at least 30 days in advance of discharge or as soon as possible, and that in emergency or immediate discharge situations the notice be sent when practicable, with a monthly list acceptable if it included whether the resident’s return was expected. Review of the admission and discharge report showed eight residents discharged in January 2026, six in February 2026, eight in March 2026, and eight in April 2026. During interview, the Ombudsman stated the office had not received the transfer and discharge notifications consistently from the facility starting in January 2026. The SSD stated he had only been at the facility for two weeks, had not sent any documentation of transfers and discharges to the Ombudsman’s office, and was unsure what the previous SSD had sent. The Administrator stated she expected the SSD to send the required documentation to the Ombudsman’s office, and the report noted the facility had not had a dependable SSD for several months.
Lack of individualized and evening activity programming
Penalty
Summary
The facility failed to provide an ongoing activity program that supported residents’ interests and choices, and it failed to provide 1:1 activities for a resident identified as having the potential to benefit from them. The facility’s activity calendar for the reviewed period showed daytime activities such as dancing, coffee and conversation, bingo, chair exercises, music, cards, trivia, and resident council, but no activities were offered in the evening hours. The Activities policy stated that activities were to be designed to meet residents’ interests and psychosocial well-being, and that individualized activities plans would be developed when residents required more intensive interventions. Resident #7 was cognitively intact and had diagnoses including HTN, obstructive uropathy, type II DM, depression, and schizophrenia. The resident’s activity assessment noted a preference for being with friends and stated the resident attended quite a few activities but sometimes found it hard to attend. During observation, the resident was seen sitting near the nurse’s station watching TV and said there were no activities after dinner, that the only afternoon and evening activity was smoke time for smokers, and that the resident would have liked something to do in the afternoons or evenings. The resident also said he or she liked dogs and would have enjoyed a dog visit. A CNA stated there were afternoon and evening coffee socials or outdoor activities, but had never seen Resident #7 attend an activity or anyone encourage the resident to attend. Resident #25 had moderate cognitive impairment, used a walker and wheelchair, and had diagnoses including chronic lung disease, HTN, heart failure, morbid obesity, and difficulty walking. The care plan identified little to no involvement with activities, but the intervention section for encouraging participation was left blank. Engagement records showed participation in only one program, bingo, for 120 minutes. The resident stated there were no evening activities unless a resident smoked, that none of the activities were interesting, and that the same activities were repeated too often. Resident #8 had schizoaffective disorder, anxiety, depression, and moderately impaired cognition. The care plan noted a potential for decline in activity participation and stated activities would provide 1:1 activities on request, but the resident reported there were not enough activities and wanted more variety. Observation showed the resident waiting for smoke break with no morning activities on the hallway, and the Activity Director said the resident would benefit from more activities. Resident #35 was cognitively intact and had diagnoses including CVA, paraplegia, malnutrition, depression, schizophrenia, and asthma, with impairment of both upper and lower extremities and wheelchair use. The resident’s activity preferences included favorite activities, going outside for fresh air, religious services, pets, and music. The quarterly activity assessment stated the resident did not really come to activities but wanted to do more things, wanted therapy equipment and books, and wanted to do more with activities. During interview, the resident said staff did not ask daily if he or she wanted to get out of bed, that staff gave excuses such as staffing or emergencies, that activities did not go to resident rooms or walk around, and that the resident felt isolated and depressed. The Activity Director stated she did not have a 1:1 list and that speaking with the resident for about five minutes was not considered a 1:1 activity. Additional observations and interviews showed staff involvement in activities was limited, smoke breaks were handled by Activities staff, residents reported a lack of evening activities and variety, and the Administrator expected a variety of activities, evening activities, staff engagement during activities, and a 1:1 list for residents who needed them.
Incomplete smoking assessments and unsecured smoking materials
Penalty
Summary
The facility failed to ensure smoking assessments were completed for three residents and failed to ensure lighters and cigarettes were not taken into two residents’ rooms. The facility’s Smoking Safety Regulations Policy stated that residents classified as not responsible would receive direct supervision for smoking, but it did not address how often smoking assessments should be completed or where smoking materials should be stored. The sample included 20 residents, and the census was 97. Resident #91 had diagnoses including cancer, chronic lung disease, seizures, and stroke, with moderately impaired cognition. The resident’s care plan did not address smoking, and the smoking and safety evaluation completed on admission was blank in the sections for smoking safety evaluation, care planning, smoking cessation care planning, and clinical suggestions. During observation, the resident was given a cigarette and lighter, smoked outside, then entered the building with the lighter still in hand and took it to the room, where it was placed on the bedside table. Staff did not remove the lighter before the resident entered the building. Resident #2 had diagnoses including schizophrenia, infection of the intravertebral disc, malnutrition, and viral hepatitis, and was cognitively intact and used a walker. The resident’s smoking and safety evaluations were incomplete, with blank sections for care planning, smoking cessation care planning, and clinical suggestions. During observation, the resident was found in bed with half of a smoked cigarette and a lighter next to the resident, and the resident stated he/she had just returned from smoking. Resident #31 had diagnoses including COPD, diabetes, and mild intellectual disabilities, with moderately impaired cognition. The resident’s care plan identified the resident as a smoker and stated the resident would not smoke without supervision, but the smoking and safety evaluation was also incomplete with blank sections. The resident was observed returning from the smoking patio with staff supervision during the smoke break.
Failure to Complete Employee TB Testing
Penalty
Summary
The facility failed to ensure employee two-step tuberculin skin tests were completed in accordance with State guidelines for 9 of 10 sampled employees. Review of the facility’s TB testing policy dated 6/29/23 stated that each new employee would receive a two-step PPD skin test upon hire and an annual one-step TB test. Record review showed multiple employees had no documentation of either the first or second step TB test, while others had documentation of a first step TB test with no documentation of the second step being completed. Employee records reviewed included employees with hire dates of 5/28/25, 6/11/25, 7/30/25, 4/24/26, 5/4/26, and 4/24/26. Some files showed a first step TB test administered and read with a negative result, while others showed a first step test administered with no documented result, and several had no documentation of any TB testing. During interview on 5/21/26 at 2:59 P.M., the Regional Nurse Consultant and Administrator stated employees should receive their first step TB test prior to their first day on site and expected staff to receive a second step TB test within the required timeline. Nursing staff was responsible for administering the TB test to newly hired employees.
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 NOMNCs When Medicare Part A Services Ended
Penalty
Summary
The facility failed to ensure that a Notice of Medicare Non-Coverage (NOMNC) was provided to three sampled residents who remained in the facility after Medicare Part A skilled services ended. Review of the facility policy showed that a NOMNC, Form CMS-10123, was to be issued when Medicare covered services were ending, including when a resident remained in the facility, and that it was to be given at least two days before the end of the Medicare-covered stay. The Social Service Director or designee was responsible for issuing the notice. Record review showed that Resident #9 had Medicare Part A skilled services from 4/23/26 through 4/29/26 and stayed in the facility, but no NOMNC form was given. Resident #21 had Medicare Part A skilled services from 3/4/26 through 3/10/26, stayed in the facility, and also had no NOMNC form. Resident #75 had Medicare Part A skilled services from 11/6/25 through 12/18/25, remained in the facility, and no NOMNC form was found. During interview, the Administrator stated the NOMNCs should have been given at least two days before Medicare covered services ended and said the Social Service Director was responsible, but the facility had been without a social worker for at least four months.
Expired Medications Found in Medication Rooms and Cart
Penalty
Summary
Expired medications and biologicals were found stored in locked medication areas and on a treatment cart in the facility. On observation, the fifth-floor medication storage room contained a bottle of MedLine Drug Buster expired as of 3/31/25. The fourth-floor medication room contained seven bottles of Nutren 1.5 expired as of 2/13/26, one bottle of Geri-Care Bisacodyl Laxative expired as of 12/2025, one bottle of Nature's Blend Vitamin C 250 mg tablets expired as of 1/2026, one bottle of Acamprosate 333 mg expired as of 5/15/26, and one bottle of Atorvastatin 40 mg expired in January 2026. The third-floor treatment cart contained one bottle of Geri-Care Daily Multivitamins expired in April 2026 and one box of Mucinex-DM 12 Hour Relief expired in January 2026. During interviews, a CMT and an LPN stated there was no single staff member responsible for auditing medication rooms and carts, and that nursing staff shared the responsibility collectively. The CMT said expired medications should be removed from medication rooms and carts, and the LPN said he/she was not sure how often the pharmacy partner removed expired medications or performed wasting services. The Administrator, DON, ADON, and Regional Nurse Consultant stated they would expect all expired medications and biologicals to be removed from medication rooms and carts, and that no current process placed sole responsibility on any member of nursing administration to review or audit for expired medications. They also stated the pharmacy partner came once per month to audit and remove expired medications identified by the facility.
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 | ★★★★★ | 13 | 1 |
| Pine Grove Manor | 2.1 mi | ★★★★★ | 21 | 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 August 2026) and official state health department websites.