Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to organize and participate in resident/family groups in the
facility.

Based on interviews and record reviews, the facility failed to follow their policy to
provide the resident council with written responses, actions, and rationale taken
regarding their concerns. Furthermore, the residents indicated the resident council could
not meet when department heads were out of the building. This had the potential to affect
all residents in the facility. The facility census was 82.
1. Review of the facility’s Grievances/Complaints, Filing Policy, last revised in (MONTH)
(YEAR), showed the following:
-Residents and their representatives have the right to file grievances, either orally or
in writing, to the facility staff or to the agency designated to hear grievances;
-The administrative staff will make prompt efforts to resolve grievances to the
satisfaction of the resident and/or representative;
-Policy Interpretation and Implementation:
-Any resident, family member or appointed resident representative may file a grievance or
complaint concerning care, treatment, behavior or other residents, staff members, theft of
property, or any other concerns regarding his/her stay at the facility. Grievances also
may be voiced or filed regarding care that has not been furnished;
-All grievances, complaints or recommendations stemming from resident or family groups
concerning issues of resident care in the facility will be considered. Actions on such
issues will be responded to in writing, including a rationale for the response;
-Upon admission, residents are provided with written information on how to file a
grievance or complaint. A copy of the grievance/complaint procedure is posted on the
resident bulletin board;
-The social service designee (SSD) is the appointed grievance officer who is responsible
for investigating grievances and/or complaints;
-Upon receipt of a grievance and/or complaint, the grievance officer will review and
investigate the allegations and submit a written report of such findings to the
administrator within 5 working days of receiving the grievance and/or complaint;
-The grievance officer, administrator and staff will take immediate action to prevent
further potential violations of resident rights while the alleged violation is being
investigated;
-The resident, or person filing the grievance and/or complaint on behalf of the resident
will be informed (verbally and in writing) of the findings of the investigation and the
actions that will be taken to correct identified problems;
-The administrator, or his/her designee, will make such reports orally within 3 working
days of the filing of the grievance or complaint with the facility;
-A written summary of the investigation is provided to the resident, and a copy will be
filed in the business office.
2. Observation of the resident bulletin boards on all days of the survey on 10/11, 10/12,
10/15, 10/16 and 10/17/18, showed the facility did not post the grievance/complaint
procedure.
3. During a group interview on 10/12/18 at 2:00 P.M., six residents said the Activity
Director (AD) attends each of the meetings and takes notes. They are not allowed to see
her notes. The residents said they do not receive any feedback to their concerns in
writing. Other staff members have been invited to attend, but do not come. Six of six
residents said they did not know how to file a grievance. If they go to the SSD with an
issue, she typically makes it out to be the fault of the person with the concern. Six out

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0565

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
of six residents agreed they have been told they are not allowed to hold resident council
meetings unless the administrator, Director of Nursing (DON) or SSD are in the building.
The explanation they have been given for this is because.
4. Review of the resident council meeting minutes for July, (MONTH) and (MONTH) (YEAR),
did not show staff discussed old business and feedback from previous meetings with the
residents in attendance.
5. During an interview on 10/15/18 at 11:02 A.M., the AD said she takes notes at each
resident council meeting. She did not know how concerns were followed up with residents.
She said she informed each department of the any concerns or suggestions brought up at the
meeting and they took it from there. She covers old business at the beginning of each
meeting, but does not give minutes to the residents. When she started as the AD, she was
told resident council could only be held if the administrator, DON or SSD were in the
building. Normally resident council is the last Monday of the month. If a holiday falls on
the last Monday of the month and the department heads are off, they will reschedule the
meeting to the next day. This has happened a couple of times since she has been in this
position.
6. During an interview on 10/16/18 at 11:00 A.M. the SSD verified she is the grievance
officer. Sometimes she gets a complaint from residents or family members and can look into
it immediately. Otherwise, she will have to do an investigation if the issue will take
longer than a day to resolve. The investigation can take up to 10 days. She goes directly
to the person who made the grievance to discuss the conclusions. She documents her
conclusions on a grievance log, but does not provide written documentation to the family
or resident. Resident council concerns are addressed by the department head the issue
pertains to. She will get a copy of minutes if there’s a problem with her department. She
will address each resident individually with their concerns. She also has two residents
who always provide her with the concerns brought up at the meeting. During the meetings
they are supposed to cover old business and concern resolutions for the previous meeting.
They can also invite the department head to the meeting to further discuss concerns. She
is not aware of any rule stating resident council cannot be held if she or the
administrator or the DON is not in the building.
During an interview on 10/16/18 at 2:22 P.M., the AD said there is a resident bulletin
board on each floor. The boards will have things like resident art work or writings by
residents on them. She did not know the grievance policy should be posted on the boards
and confirmed it was not.
During an interview on 10/17/18 at 7:20 A.M. the administrator said she was not aware her
policy said to post the grievance/complaint procedure on the resident bulletin boards. She
follows up with concerns from resident council personally and residents are given
resolutions in writing. If residents want a copy of the resident council minutes and
feedback they can ask for it. The SSD may not provide something in writing, but it is
discussed in person.
During an interview on 10/17/18 at 8:30 A.M., the administrator, DON and SSD denied there
was a rule that resident council could only be held if they were in the building. They did
not know why residents would say that. The only times the meetings have been rescheduled
have been at the groups’ request.

F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to manage his or her financial affairs.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0567

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Based on interview and record review, the facility failed to provide and make available
personal funds on an ongoing basis for all residents for which the facility held funds.
The facility census was 82.
1. During the resident council meeting on 10/12/18 at 2:00 P.M., six of six residents
agreed the facility only held banking hours Monday through Friday from 1:00 P.M. to 2:00
P.M. The resident bank was never open on weekends or federal holidays.
2. During an interview on 10/15/18 at 8:40 A.M. the business office manager said petty
cash is available Monday through Friday from 1:00 P.M. to 2:00 P.M. She will rearrange her
schedule on Fridays to accommodate a resident if they have to leave early or have an
appointment. Petty cash is not available on the weekends. She encourages residents to get
their money before the weekend.
3. During an interview on 10/15/18 1:11 P.M., the administrator said she thought funds
only needed to be made available during banking hours Monday through Friday. She did not
know it had be available for longer hours or on weekends.

F 0576

Level of harm – Potential for minimal harm

Residents Affected – Many

Ensure residents have reasonable access to and privacy in their use of communication
methods.

Based on interview and record review, facility staff failed to deliver resident mail on
Saturdays. This had the potential to affect all residents in the facility. The facility
census was 82.
1. During a group interview, on 10/12/18 at 2:00 P.M., six of six residents actively
involved in resident council, said the residents said they do not receive mail on
Saturdays.
2. During an interview on 10/15/18 at 10:53 A.M., the Activity Director (AD) said mail is
delivered Monday through Friday. She does not work on the weekends, so she does not know
if mail is delivered. There is an activity assistant who works on the weekends. The
Business Office Manager (BOM) would know if mail was delivered on Saturdays. The AD then
said the BOM does not work on weekends either.
3. During an interview on 10/15/18 at 1:11 P.M., the administrator said mail is not
delivered on Saturdays. She did not know why, but the post office brings the Saturday mail
on Mondays.
4. During an interview on 10/15/18 at 2:50 P.M., a post office official confirmed his post
office delivered to the facility. He said if a business is open on Saturdays, then unless
other arrangements have been made by the business, mail would be delivered on Saturdays.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on record review and interview, the facility failed to provide a Skilled Nursing
Facility Advance Beneficiary Notice (SNFABN – form CMS- ) or a denial letter at the
initiation, reduction, or termination of Medicare Part A benefits for three sampled
residents who remained in the facility upon discharge from Medicare Part A services

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
(Residents, #44, #37 and #79). The facility census was 82.
Record review of the Centers for Medicare and Medicaid Services Survey and Certification
memo (S&C -09-20), dated 1/9/09, showed the following:
-The Notice of Medicare Provider Non-Coverage (NOMNC – form CMS- ) is issued when all
covered Medicare services end for coverage reasons;
-If the skilled nursing facility (SNF) believes on admission or during a resident’s stay
that Medicare will not pay for skilled nursing or specialized rehabilitative services and
the provider believes that an otherwise covered item or service may be denied as not
reasonable or necessary, the facility must inform the resident or his/her legal
representative in writing why these specific services may not be covered and the
beneficiary’s potential liability for payment for the non-covered services. The SNF’s
responsibility to provide notice to the resident can be fulfilled by use of either the
SNFABN (form CMS- ) or one of the five uniform denial letters;
-The SNFABN provides an estimated cost of items or services in case the beneficiary had to
pay for them his/herself or through other insurance they may have;
-If the SNF provides the beneficiary with either the SNFABN or a denial letter at the
initiation,
reduction, or termination of Medicare Part A benefits, the provider has met its obligation
to inform the beneficiary of his/her potential liability for payment and related standard
claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the
beneficiary of his/her right to an expedited review of a service termination.
1. Record review of Resident #44’s Skilled Nursing Facility Beneficiary Protection
Notification Review, completed by facility staff on 10/11/18, showed the following:
-Medicare Part A skilled services start date 4/6/18;
-Last covered day of Medicare Part A service as 5/18/18;
-The facility initiated the discharge from Medicare Part A services when benefit days were
not exhausted;
-Facility staff did not provide the resident or his/her legal representative the SNFABN
form CMS- or alternative denial letter.
2. Record review of Resident #37’s Skilled Nursing Facility Beneficiary Protection
Notification Review, completed by facility staff on 10/11/18, showed the following:
-Medicare Part A skilled services start date 5/23/18;
-Last covered day of Medicare Part A service as 8/14/18;
-The facility initiated the discharge from Medicare Part A services when benefit days were
not exhausted;
-Facility staff did not provide the resident or his/her legal representative the SNFABN
form CMS- or alternative denial letter.
3. Record review of Resident #79’s Skilled Nursing Facility Beneficiary Protection
Notification Review, completed by facility staff on 10/11/18, showed the following:
-Medicare Part A skilled services start date 4/4/18;
-Last covered day of Medicare Part A service as 6/8/18;
-The facility initiated the discharges from Medicare Part A services when benefit days
were not exhausted;
-Facility staff did not provide the resident or his/her legal representative the SNFABN
form CMS- or alternative denial letter.
4. During an interview on 10/16/18 at 8:00 A.M., the administrator said she was unaware of
the required SNFABN for CMS- and had never given the form to a resident discharged from
Medicare Part A when benefit days were not exhausted.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

Based on observation and interview, the facility failed to provide a dignified and
homelike dining experience by not removing plate warmers from under dinner plates and from
the table, and leaving meals on serving trays when residents ate. The census was 82.
1. Observation of the main dining room on 10/11/16 at 12:06 P.M., showed staff served the
lunch meal to residents on a serving tray and did not remove plate warmers from under the
dinner plate.
2. Observation on 10/12/18 at 12:07 P.M. and 10/16/18 at 7:07 A.M., showed residents sat
at tables in the fifth floor dining room and ate lunch. Residents ate off their plates
that sat on plate warmers, on lunchroom style food trays. The lids to the plate warmers
sat in the middle of the table, stacked up between the residents trays.
3. Observation of the fourth floor dining room, showed the following:
-On 10/12/18 at 12:16 P.M., Resident #130 sat in a wheelchair at the dining room table and
ate pureed lunch items from small bowls. The bowls and his/her healthshake sat on a brown
serving tray. Resident #70 sat at the dining room table and ate his/her lunch entree from
a dinner plate, contained in a plate warmer, on a brown serving tray;
-On 10/15/18 at 8:28A.M., Resident #130 sat in a wheelchair at the dining room table and
ate pureed breakfast items from small bowls. The bowls and his/her healthshake sat on a
brown serving tray. Resident #70 sat at the table and ate breakfast from a dinner plate,
contained in a plate warmer, on a brown serving tray.
4. During an interview on 10/17/18 at 8:30 A.M., the administrator said some residents may
like the serving trays. The plate warmer keeps food warm and they are under the plate so
resident’s can’t see them.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure resident
care plans reflected their current needs by not updating them to show a resident’s
preference to stay in bed, contracture, restorative therapy and correct staging of
pressure ulcers for five residents (Residents #63, #2, #74, #67 and #44) of 18 sampled
residents.
1. Review of Resident #63’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facililty staff, dated 8/9/2018, showed the following:
-Total dependence for toileting, personal hygiene, and transfer from bed;
-[DIAGNOSES REDACTED].
Observation on 10/11/18 at approximately 2:00 P.M., 10/12/18 at approximately 11:48 P.M.,
10/16/18 at approximately 1:14 P.M., and 10/19/18 at approximately 8:00 A.M., showed the
resident lay in bed.
Review of the resident’s undated care plan, in use at the time of survey, showed:
-Problem: [MEDICAL CONDITION] medication use: anxiety, depression and dementia;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 5)
-The care plan failed to identify the resident’s choice to stay in bed nor how staff
should approach the resident when he/she refused to get out of bed.
During an interview on 10/12/18 at approximately 11:00 A.M., the resident said sometimes
he/she doesn’t want to stay in bed all day and sometimes maybe he/she does.
During an interview on 10/17/18 at approximately 8:31 A.M., the Director of Nursing (DON)
said, this is a new behavior resulting from a change in condition after a recent hospital
stay and should be documented on the resident’s care plan.
2. Review of Resident #2’s quarterly MDS, dated [DATE], showed the following
-Short and long term memory problems;
-Moderately impaired cognitive skills for daily decision making;
-Total dependence on staff for dressing, eating, toilet use, personal hygiene and bathing;
-Incontinent of bowel and bladder;
-Gastrostomy ([DEVICE], a tube surgically inserted into the stomach to provide hydration,
nutrition and medications) tube;
-Upper extremity impairment on one side;
-Not at risk for pressure ulcers;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, in use during the survey, showed the following:
-Problem, potential for impaired skin integrity related to decrease in mobility, bowel and
bladder incontinence and debility, skin currently intact;
-Goal, will maintain good skin integrity/skin integrity will be preserved through next
review;
-Interventions, provide treatment to affected areas as directed, monitor hand skin
integrity, provide treatment to left hand as directed;
-Handwritten update, 7/16/18, no skin concerns reported. Continue with weekly skin
assessments and provide incontinence care as needed, report change in skin integrity to
physician;
-Handwritten update, 10/8/18, provide skin care as directed. Continue weekly skin
assessments, report skin concerns to the physician;
-Nothing in the careplan regarding a contracture, previous wound to the hand or the use of
gauze to the resident’s hand.
Review of the resident’s physician order [REDACTED].
-An order, dated 6/6/18, to cleanse wound to left hand with wound cleanser, apply triple
antibiotic ointment and dry dressing daily until healed.
Review of the resident’s treatment administration record (TAR), dated 10/11/18 to
11/10/18, showed, staff to cleanse wound to left hand with wound cleanser, apply triple
antibiotic ointment and dry dressing daily until healed. Staff initialed as done 10/11/18
through 10/16/18.
Review of the facility’s wound report, showed no mention of a wound on the resident’s left
hand.
Observation of the resident, showed the following:
-On 10/11/18 at 1:33 P.M., the resident sat in a wheelchair in the televison area with a
white dressing inside his/her contracted left hand;
-On 10/12/18 at 12:48 A.M., the resident lay in bed with a white dressing inside his/her
contracted left hand;
-On 10/15/18 at 8:25 A.M., the resident sat in a wheelchair in the television area with a
white dressing inside his/her contracted left hand;
-On 10/15/18 at 1:52 P.M., the resident lay in bed with a white dressing inside his/her
contracted left hand;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-On 10/16/18 at 7:00 A.M. and 12:33 P.M., the resident sat in a wheelchair in the
television area with a white dressing inside his/her contracted left hand;
-On 10/17/18 at 7:32 A. M., the resident lay in bed with a roll of gauze inside his/her
contracted left hand.
During an interview on 10/16/18 at 12:15 P.M., the Assistant Director of Nursing (ADON)
said the resident did not have an open area on his/her left hand. A dry dressing is placed
there because of moisture to keep it from breaking down. A while back the fingernail on
his/her left pinky finger caused a sore on on his/her palm but that cleared up. If there
was a wound on his/her hand, it would be on the weekly wound report.
During an interview on 10/17/18 at 8:30 A.M., the Administrator said the use of the
dressing inside the resident’s contracted hand was because of moisture. The order should
be reworded.
3. Review of Resident #74’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Limited assistance required with personal hygiene, dressing and walking in the halls;
-[DIAGNOSES REDACTED].
Review of a list of resident’s receiving restorative therapy (RT-aides in maintaining the
full movement potential of a joint), provided by the facility on 10/12/18, showed the
resident received RT.
Review of the RT binder, showed the resident received RT for the following:
-Goal: Maintain strength and range of motion (ROM) for functional mobility and orthotic
management;
-Approach: General sitting exercises and ROM program, gait as tolerated and check orthotic
devices to left leg and hand splint as tolerated.
Review of the physician’s orders [REDACTED].
Review of the RT log, showed the resident received RT three times a week since 11/1/17 for
general sitting exercises, range of motion (ROM) and for use of a hand splint.
Review of the care plan, dated 7/5/18, showed the following:
-Problem: Potential for self-care deficit related to stoke with paralysis;
-Goals:Resident will maintain current level of function and be clean and well groomed;
-Interventions: Assist as needed with transfers and personal care, monitor for changes,
resident has a hand splint due to a stroke with right sided paralysis and ambulate with
resident to and from the dining room;
-The care plan did not show the resident receivd RT.
4. Review of Resident #67’s quarterly MDS, dated [DATE], showed the following:
-Cognition not assessed;
-[DIAGNOSES REDACTED].
-Number of pressure ulcers (Has Injury to the skin and/or underlying tissue usually over a
bony prominence, as a result of pressure or friction): two, Stage III (Full thickness
tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed.
Slough may be present but does not obscure the depth of tissue loss. (MONTH) include
undermining or tunneling) pressure ulcers;
-Special services: Hospice.
Review of the facility wound report, showed on 9/25/18, the resident had two Stage III
pressure ulcers on the proximal (inner) and distal (outer) area of his/her left gluteal
area.
Review of the resident’s care plan, last updated on 10/4/18, and in use during the survey,
showed the following:
-Problem: Potential risk for impaired skin integrity related to Stage II (Partial
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed
without slough. (MONTH) also present as an intact or open/ruptured blister) pressure area
on left gluteal area;
-Goal: Resident will receive optimal care and management to preserve skin integrity and
for steady improvement of pressure area through next review;
-Interventions included provide treatment to area as ordered, monitor and document wound
progress on a weekly basis and provide pressure relieving devices to bed/wheelchair as
needed;
-Problem: Palliative care (care associated with relieving symptoms associated with a
condition while receiving active treatment);
-Goal included: Symptoms will be managed and resident will remain comfortable;
-Staff did not update the care plan to show the resident’s current pressure ulcer staging
or the change with the pressure sores.
5. Review of Resident #44’s quarterly MDS, dated [DATE], showed the following:
-Cognition not assessed;
-Has unclear speech, makes self understood and understands others;
-Required extensive assistance with toileting, dressing, transfer and bed mobility;
-[DIAGNOSES REDACTED].
-Impairment on one side for upper and lower extremities;e
-No restorative nursing program services offered in last 7 days.
Review of the resident’s care plan, last updated on 8/30/18, showed the following:
-Resident has right sided hemiperisis and uses lap tray for right side upper extremity
(UE) positioning.
-Staff did not include the resident’s participation in RT.
Review of a list of resident’s receiving RT, provided by the facility on 10/12/18, showed
the resident received RT. Review of the RT binder, showed the resident received RT for the
following:
-Goal: maintain current range of motion and strength, maintain current transfer ability as
tolerated;
-Approach: Right UE and lower (LE), general sitting exercises left UE & LE, general
sit to stand pivot transfers;
-The binder included documentation for August, (MONTH) and (MONTH) (YEAR);
-Staff did not include how often RT should be provided.
During an interview on 10/17/18 at 8:30 A.M., the administrator said the resident was
discharged from therapy in May. The therapy department made the recommendation the
resident continue with RT. This information should be included on the care plan as well as
how often the resident receives RT.
6. During an interview on 10/17/18 at 8:30 A.M., the administrator said the MDS
coordinator updates the care plan quarterly and as needed. A daily clinical meeting is
held and the MDS coordinator is alerted at that time to any changes in resident’s
conditions or care needs. Any nurse can also update a care plan. The care plan should
reflect the resident’s current needs and condition

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure that care
and services are provided according to acceptable standards of clinical practice by
ensuring physician orders [REDACTED]. In addition, the facility failed to document
accuracy of liquid intake, obtain a urine lab results, and provide a [DIAGNOSES
REDACTED].#44, #63, #6, #30, and #74). The census was 82.
1. Review of Resident #44’s quarterly Minimum Data Set, (MDS), a federally mandated
assessment instrument completed by facility staff, dated 8/3/18, showed the following:
-Cognition not assessed;
-Has unclear speech, makes self understood and understands others;
-Required extensive assistance with toileting, dressing, transfer and bed mobility;
-[DIAGNOSES REDACTED].
-Weight: 168 pounds;
-Impairment on one side for upper and lower extremities;
-No restorative nursing program services offered in last 7 days;
-No oxygen therapy offered.
Review of the resident’s medical record, showed the following:
-A dietary recommendation, dated 8/21/18, to add health shakes three times a day;
-A physician order [REDACTED].
-An order, dated 3/5/18, for oxygen to be given routinely at 2 liters for shortness of
breath;
-an order for [REDACTED].> -No order for health shakes to be given three times a day.
Further review of the medical record, showed the following:
-A Medication Administration Record [REDACTED]
-Staff did not document if the physician was made aware of the dietary recommendation;
-A treatment administration record (TAR), dated 10/11/18 through 11/10/18, showed:
-An order, dated 3/5/18, for routine oxygen to be given at 2 liters for shortness of
breath;
-Staff did not document if the routine oxygen had been provided;
-No [MEDICATION NAME] level lab results for (MONTH) (YEAR).
Observations of the resident on 10/11/18 at 4:00 P.M., 10/12/18 at 10:48 A.M., 10/15/18 at
9:02 A.M., and 10/16/18 at 7:09 A.M., showed the resident did not have on oxygen.
During an interview on 10/17/18 at 8:30 A.M., the Director of Nursing (DON), said there
should be a year’s worth of lab results in the resident’s chart. Staff should notify the
resident’s physician of a dietary recommendation and document the response in the
resident’s chart. The resident’s order for oxygen should have been written to be given as
needed. Orders should be clarified and corrected during recapitulation.
On 10/17/18 at approximately 11:30 A.M., the DON said she received an order to implement
the dietary recommendation. The resident’s (MONTH) [MEDICATION NAME] level was not taken.
2. Review of Resident #63’s quarterly MDS dated [DATE], showed [DIAGNOSES REDACTED].
Review of residents medical record, showed the following:
-An order dated 9/11/18, for [MEDICATION NAME] (a medication used to treat depression)
give 60 milligrams (mg) every A.M and 30 mg every P.M.;
-An order dated 10/9/18, to decrease the [MEDICATION NAME] to 60 mg and give in the
morning only.
Review of the resident’s MAR indicated [REDACTED].M. on 10/11/18, 10/12/18, and 10/13/18.
3. Review of Resident #6’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
-Supervision required for all care;
-Mobility provided with the use of a wheelchair or walker;
-[DIAGNOSES REDACTED].
Review of the POS [REDACTED]. No indication for use provided with the order.
Review of the POS [REDACTED].
Review of the medical record, showed no documentation of fluid intake.
During an interview on 10/17/18 at 9:30 A.M., the DON said all antibiotics should have a
[DIAGNOSES REDACTED]. She said the fluid restrictions are recorded on the treatment
administration record (TAR).
Review of a TAR that was not labeled with what month or year staff were documenting for
and provided by the DON on 10/17/18 at 11:00 A.M., showed the following:
-240 cc’s for breakfast and initialed every day from the 24th through the 10th;
-240 cc’s for lunch and initialed every day from the 24th though the 10th;
-240cc’s for dinner and initialed every day from the 24th through the 10th;
-340 cc’s free fluid and initialed every day from the 24th through the 10th;
-No documentation recorded for the amount of fluid intake.
During a second interview on 10/17/18 at 11:00 A.M., the DON said she believed the
documentation to be sufficient even though it did not show the amount of fluid consumed.
After further review of the TAR she said she realized that the recording is insufficient
and the amounts listed total 1060 cc’s instead of the allotted 1500 cc’s.
4. Review of Resident #30’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Extensive assistance required for all personal care;
-Frequently incontinent of urine;
-[DIAGNOSES REDACTED].
Review of the POS [REDACTED].
Further review of the medical record, showed no results of a UA C&S.
During an interview on 10/17/18 at 8:30 A.M., the DON said the results of all lab work
would be found in the chart.
5. Review of Resident #74’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-[DIAGNOSES REDACTED].
Review of the POS [REDACTED]. No indication for use provided with the medication.
During an interview on 10/17/18 at 9:30 A.M., the Director of Nursing (DON) said all
antibiotics should have a [DIAGNOSES REDACTED].
6. During an interview on 10/17/18 at 8:30 A.M., the Director of Nursing (DON), said she
expected staff to follow physician orders.

F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide care and assistance to perform activities of daily living for any resident who
is unable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide complete
perineal care (the surface area between the thighs, extending from the pubic bone to the
tail bone) during two of the three observations of residents who were incontinent of bowel
and bladder and dependent upon staff for care (Residents #44,and #67). The facility census
was 82.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
Review of the facility’s Perineal Care policy, dated (MONTH) (YEAR), showed:
-Purpose: To provide cleanliness and comfort to the resident, prevent infections and skin
irritation, and to observe the resident’s skin condition;
-Equipment and supplies necessary when performing procedure included wash basin, towels,
washcloth, soap (or other authorized cleansing agent), and personal protective equipment
(e.g., gowns, gloves, mask, etc., as needed.);
-For a male resident; wet washcloth and apply soap or skin cleansing agent, wash perineal
area, using fresh water and a clean washcloth, gently dry perineum following the same
sequence;
-Ask the resident to turn on his side with his upper leg slightly bent, if able;
-Rinse wash cloth and apply soap or skin cleansing agent, wash and rinse the rectal area
thoroughly, dry area thoroughly;
-For a female resident; wash perineal area, wiping from front to back;
-Continue to wash the perineum moving from inside outward to the thighs, rinse perineum
thoroughly in the same direction, and gently dry perineum;
-Wash rectal area thoroughly.
1. Review of Resident #44’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument, completed by facility staff, dated 8/30/18, showed the following:
-Moderately impaired cognition;
-Resident is rarely/never understood;
-Extensive assistance required for bed mobility and toilet use;
-Total dependence for personal hygiene;
-Frequently incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation on 10/12/18 at 6:44 A.M., showed Certified Nursing Assistant (CNA) A provided
perineal care to the resident. The resident lay in bed and was incontinent of urine;
-CNA A removed the resident’s gown and urine-soaked brief;
-CNA A washed the resident’s perineal area with a back and forth, up and down, and
circular motion using the wet, soapy towel;
-Using the same area of the towel, CNA A washed the resident’s genitals in a back and
forth motion many times;
-CNA A used the dry portion of the same towel to dry the resident’s peri area and genitals
in a back and forth, circular manner;
-CNA A used the soiled wet and soapy towel and wiped the resident’s rectal area in a back
to front, back and forth, and circular manner;
-CNA A then used the dry portion of the soiled towel to dry the resident’s rectal area
wiping in a back to front and circular manner many times;
-CNA A placed a clean brief under the resident and applied barrier cream (helps to protect
the skin from moisture) onto his/her rectal area and buttocks in a back and forth, and
circular motion.
During an interview on 10/12/18 at approximately 7:00 A.M., CNA A said when cleansing the
perineal area the direction of the wiping motion does not matter as long as it was wiped
clean.
2. Review of Resident #67’s quarterly MDS, dated [DATE], showed the following:
-Moderately impaired cognition;
-Dependent on staff for mobility and personal hygiene;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation on 10/15/18 at 1:10 P.M., showed CNA’s F and G transferred the resident to bed
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0677

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
and removed his/her wet with urine slacks and brief. With three wadded pre-moistened
wipes, CNA F cleansed the left side of the genitalia three times in a back and forth
motion without changing areas of the cloths, with three clean cloths he/she repeated the
process on the right side of the genitalia and with three clean cloths he/she repeated the
process in the center of the genitalia. He/she then turned the resident to his/her right
side and cleansed the left buttock in a circular motion then turned the resident to
his/her left side and cleansed the right buttock in a circular motion.
During an interview on 10/15/18 at 1:20 P.M., CNA F said when providing perineal care
always cleanse from the front to the back and never in a back and forth motion.
During an interview on 10/16/18 at 10:10 A.M., the Drector of Nursing said when providing
perineal care staff should always cleanse from the front to the back and change the area
of the cloth or use a new cloth with each pass. Always cleanse from clean to dirty.

F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate treatment and care according to orders, resident’s preferences and
goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to administer a
newly ordered medication to alleviate one resident’s respiratory symptoms and delayed
obtaining ordered tests, did not monitor one resident’s pain and communicate to the
physician and failed to monitor and report abnormal bleeding from a resident who received
blood thinning medication. (Residents #61, #58 and #70). The sample size was 14. The
facility census was 82.
1. Review of Resident #61’s quarterly Minimum Data Set, (MDS), A federal mandated
assessment instrument completed by facility staff, dated 9/20/18, showed [DIAGNOSES
REDACTED].
Review of the resident’s physician order [REDACTED].
-Obtain Urinalysis (UA, laboratory test of urine used to detect the presence of
infection);
-Obtain a chest x-ray;
-Discontinue [MEDICATION NAME] (a medication used to treat high blood pressure);
-Start [MEDICATION NAME] (an [MEDICATION NAME] used to relieve allergy symptoms) 10
milligrams (mg) one tab daily for one week.
Review of the resident’s medication administration record, (MAR) dated 10/11/18 through
11/10/18, showed the following:
-No documentation the [MEDICATION NAME] was given as ordered;
-No documentation why the [MEDICATION NAME] was not given;
-[MEDICATION NAME] 2.5 mg given on 10/11/18, 10/12/18, and 10/13/18.
During an interview on 10/11/18 at approximately 2:46 P.M., the resident said he/she is
waiting to have a chest x-ray done, he/she feels terrible and it hurts when he/she
urinates. During the interview, the resident was observed to have a loud, wet cough and
runny nose.
Review of resident’s nurse notes on 10/15/18 at approximately 11:00 A.M., dated 7/10/18
through 10/15/18, showed:
-No documentation of the resident’s current symptoms to include coughing, running nose nor
pain with urination;
-No documentation of urine specimen obtained;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 12)
-No documentation of chest x-ray obtained.
During an interview on 10/15/18 at approximately 12:11 P.M., the assistant director of
nursing (ADON) said, the resident’s nurse notes should reflect the resident’s condition,
when the x-ray and urine specimen was obtained, any communication with the doctor and what
the test results are. She was unable to locate this information in the chart and placed a
call to the radiology company for results. She knew that the resident’s urine was
collected on 10/13/18 by reviewing the nurse’s 24 hour report. The 24 hour report sheet
that is not part of the resident’s medical record.
During an interview on 10/16/18 at approximately 10:12 A.M., the resident said he/she felt
horrible and cannot sleep at night, he/she still did not know his/her test results but did
know that she gave them a urine specimen and had a chest x-ray done.
Further review of the resident nurse’s notes reviewed on 10/16/18 at approximately 8:00
A.M. showed:
-10/15/18 at 12:45 P.M., the laboratory company in to pick up urine specimen;
-10/15/18 at 1:00 P.M., new order start Z-pack (an antibiotic used to treat various types
of infections) use as directed.
Further review of the resident’s medical records, showed a chest x-ray report dated
10/11/2018, electronically signed by a radiologist on 10/11/18 at 3:15 P.M., with an
impression of mild [MEDICATION NAME] thickening (is a radiologic sign which occurs when
excess fluid or mucus buildup in the small airway passages of the lung causes localized
patches of atelectasis (closure of lung)) that could indicate [MEDICAL CONDITION], with
hand written note dated 10/15/18 at 12:30 P.M. Z-pack use as ordered.
During an interview on 10/17/18 at approximately 8:31 A.M., the DON said she expects staff
to follow the physician’s orders [REDACTED]. The resident’s urine lab results were not
available at this time.
During an interview on 10/19/18 at approximately 3:00 P.M., the resident’s primary care
nurse practitioner said he/she expects staff to follow orders given. A delay in prescribed
medications can worsen the resident’s symptoms.
2. Review of Resident #58’s quarterly MDS, dated [DATE], showed the following:
-No cognitive impairment;
-Required supervision with all personal care;
-[DIAGNOSES REDACTED].
-Frequent severe pain;
-Received an opioid seven of seven days.
Review of the POS, dated 7/11 through 8/10/18, showed the following:
-An order, dated 6/13/17, to administer [MEDICATION NAME] (narcotic [MEDICATION NAME])
10/325 mg’s four times a day;
-An order, dated 4/11/18, to administer [MEDICATION NAME] (muscle relaxer) 10 mg twice a
day.
Review of the POS, dated 8/29/18, showed an order to change the administration of
[MEDICATION NAME] from four times a day to three times a day.
Review of the annual MDS, dated [DATE], showed frequent severe pain and received an opioid
seven of seven days.
Review of the nurse’s notes, showed a note written on 9/19/18 at 10:45 A.M., that read the
resident complained of knee and back pain and rated the pain as a 10 on a scale of 0-10.
He/she said at times his/her knees gave out because of the pain and he/she chose to spend
the majority of time in his/her room due to the pain and the fear of falling.
Further review of the nurse’s notes, showed no follow up notes.
Observation on 10/11/18 at 10:57 A.M., showed the resident sat at the side of his/her bed,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
panting and frowning and said he/she had just received pain medication after being in
severe pain for three hours.
Observation on 10/15/18 at 10:27 A.M., showed the resident sat at the side of his/her bed
and complained of pain between his/her shoulders. He/she rated the pain as a seven. He/she
said the pain on occasion goes as low as a three but is typically stays around a seven.
He/she added that the pain medication went from four to three times a day and that leaves
too much time between doses because once the pain is severe it takes much longer for the
medication to be effective.
Further review of the POS, dated 10/11 through 11/10, showed no orders for as needed (PRN)
[MEDICATION NAME].
Observation on 10/16/18 at 7:10 A.M., showed the resident sat at the side of the bed,
panting and frowning. He/she rated the pain at an eight to nine.
Observation on 10/17/18 at 7:45 A.M., showed the resident sat at the side of the bed with
a strained face and shallow breathing. He/she rated the pain as a level of eight and again
said the time between pain medication needed to be decreased to provide him/her with more
relief.
During an interview on 10/17/18 at 7:57 A.M., Certified Medication Technician (CMT), said
he/she never asks the resident if he/she has any pain.
During an interview on 11/17/18 at 8:30 A.M., the Director of Nursing and the
Administrator said the physician lowered the dose of [MEDICATION NAME] to see if the
resident could tolerate a lower dose in hopes of discontinuing the medication entirely.
The DON added that if a resident complains of a pain level of 10 it is the nurse’s
responsibility to assess the resident, notify the physician, administer an [MEDICATION
NAME] and reassess the effectiveness of the medication. It is not appropriate for a
resident to be in pain, especially at a level of 10 and not have any follow-up. She said
the pain scale should be documented on the medication administration record (MAR) but not
necessarily every day or every shift. She said an order had been obtained for a pain
management consult.
Further review of the POS, dated 10/11 through 11/10/18, showed no order for a pain
management consult.
Further review of the MAR, showed no documentation of pain level.
3. Review of Resident #70’s quarterly MDS, dated [DATE], showed the following:
-Cognitively intact;
-Extensive assistance of staff required for personal hygiene;
-Occasionally incontinent;
-Received an anticoagulant (blood thinner) medication seven of seven days;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 9/24/18, showed the following:
-Problem, anticoagulation therapy/aspirin therapy, due to [MEDICAL CONDITION] (A-fib,
irregular heartbeat) and [MEDICAL CONDITION];
-Goals, will receive optimal care and management of anticoagulant therapy and be free of
adverse side effects through the next review;
-Interventions, monitor for bleeding of nose or gums, bruising, petechiae (small red or
purple spots on the skin caused by minor bleeding), pain or hematuria (blood in the
urine), educate resident/staff to recognize and report signs and symptoms of bleed to
nurse and to avoid trauma;
-Handwritten update, dated 9/24/18, Eliquis added on 9/11/18, [DIAGNOSES REDACTED].
Review of the resident’s POS, dated 10/11/18 through 11/10/18, showed the following:
-An order, dated 9/11/18 for Eliquis (blood thinner) 5 mg twice daily, for A-fib.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0684

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
Observation of the resident’s bed on 10/11/18 at 11;00 A.M., showed a fresh blood stain,
approximately 5 inches in diameter, on the resident’s pillow covering.
During an interview on 10/11/18 at 3:15 P.M., CNA F said the night shift CNA told him/her
the resident’s nose bled because he/she had picked at it. This surveyor and CNA F went
into the resident’s room, asked him/her where the blood came from and he/she said from
his/her nose.
During an interview on 10/12/18 at 11:48 A.M., the resident sat in the fourth floor dining
room and said he/she had not had bleeding from his/her nose before. It had not bled any
more since yesterday.
During an interview on 10/11/18 at 3:45 P.M., LPN E said he/she saw the resident that
morning and he/she had some cuts on his lip from using the electric razor.
Review of the resident’s nurse’s notes, showed the last documentation, dated 10/1/18.
During an interview on 10/17/18 at 8:30 A.M., the DON said she expected CNA’s to notify
the nurse on duty if a resident had an incident such as bleeding. She expected the nurse
on duty to inform her of the incident. The physician should be informed and the incident
should be recorded on the care plan, and should be documented in the nurses notes. No one
told her about the resident’s bleeding incident on 10/11/18.
During an interview on 10/19/18 at 3:16 P.M., the resident’s primary care nurse
practitioner said he is part of a group of five doctors and nurse practitioners, and they
share calls. He did not recall being told about the resident’s bleeding incident.

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to provide treatment
to existing pressure ulcers (pressure injury to the skin and/or underlying tissue usually
over a bony prominence, as a result of pressure or friction) and failed to prevent the
development of new pressure ulcers. The facility identified three residents as having
pressure ulcers, one was included in the sample and issues were identified with one
(Resident #67). The census was 82.
Review of the facility’s Pressure Ulcer/Skin Breakdown Clinical Protocol, lasted revised
(MONTH) (YEAR), included the following:
-Assessment and Recognition:
-The nursing staff and practitioner will assess and document an individuals significant
risk factors for developing pressure ulcers;
-In addition, the nurse shall describe and document/report the following:
-Full assessment of pressure sore including location, stage, width and depth, presence of
exudates or necrotic (dead) tissue;
-Pain assessment;
-Resident’s mobility status;
-Current treatments, including support surfaces;
-All active diagnoses;
-The staff and practitioner will examine the skin of newly admitted residents for
evidence of existing pressure ulcers or other skin conditions;
-The physician will assist the staff to identify the type and characteristics of an
ulcer;
-The physician will help identify and define any complications related to pressure

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
ulcers;
-Treatment/Management:
-The physician will order pertinent wound treatments, including pressure reduction
surface, wound cleansing and debridement approaches, dressings and application of topical
agents;
-The physician will help identify medical interventions related to wound management;
-The physician will help staff characterize the likelihood of wound healing, based on
review of pertinent factors;
-As needed, the physician will help identify medical and ethical issues influencing wound
healing;
-Monitoring:
-During resident visits, the physician will evaluate and document the progress of wound
healing–especially for those with complicated, extensive or poorly-healing wounds;
-The physician will guide the care plan as appropriate, especially when wounds are not
healing as anticipated or new wounds develop despite existing interventions.
Review of the Census and Conditions form, completed by the facility on 10/15/18, showed
the facility identified three residents having pressure ulcers. Of those three, none were
admitted with pressure ulcers.
Review of Resident #67’s quarterly Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 5/28/18, showed the following:
-Cognition not assessed;
-Resident rarely/never understood;
-Required extensive assistance from staff for toileting, personal hygiene, dressing and
transfers. Independent with bed mobility;
-Always incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
-Resident is at risk for pressure ulcers. No pressure ulcers present on prior assessment.
Review of the resident’s significant change MDS, dated [DATE], showed the following:
-Required extensive assistance with bed mobility and total care for toilet use and
personal hygiene;
-One or more unhealed pressure ulcers;
-One Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a
red-pink wound bed without slough. (MONTH) also present as an intact or open/ruptured
blister) pressure ulcers;
-Were pressure ulcers present at previous assessment? No;
-Skin and ulcer treatments included: pressure relieving device for chair/bed,
turning/repositioning, nutrition/hydration to manage skin problems, pressure ulcer care;
-Special treatments: Hospice.
Review of the residents quarterly MDS, dated [DATE], showed the following:
-One or more unhealed pressure ulcers: Yes;
-Two, Stage III’s (Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscle is not exposed. Slough may be present but does not obscure the depth of
tissue loss. (MONTH) include undermining or tunneling) pressure ulcers;
-Skin and ulcer treatments included: pressure relieving device for chair/bed,
turning/repositioning, nutrition/hydration to manage skin problems, pressure ulcer care;
-Special treatments: Hospice.
Review of the resident’s care plan, last updated on 10/4/18, and in use during the survey,
showed the following:
-Problem: Potential risk for impaired skin integrity related to Stage II (Partial
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 16)
thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed
without slough. (MONTH) also present as an intact or open/ruptured blister) pressure area
on left gluteal area;
-Goal: Resident will receive optimal care and management to preserve skin integrity and
for steady improvement of pressure area through next review;
-Interventions included provide treatment to area as ordered, monitor and document wound
progress on a weekly basis and provide pressure relieving devices to bed/wheelchair as
needed.
Review of the facility’s wound report, from 8/2/18 through 10/4/18, showed the following:
-On 9/11/18, staff noted the resident had a Stage II pressure ulcer on his/her left
buttock, which measured 5.5 centimeter (cm) by 3 cm by 0.1 cm. Resident’s physician made
aware. Small to moderate serosanguineous (composed of serum and blood) drainage.
Treatment: bordered gauze (multipurpose dressing that is gentle to skin, is non adherent
and has tape edges to hold the dressing in place), change every three days and as needed
(PRN);
-On 9/19/18, staff noted the resident had a Stage II pressure ulcer to his/her left
buttock, which measured 4.5 cm by 2 cm by 0.1 cm. Resident’s physician made aware. Small
to moderate serosanguineous drainage. Treatment: bordered gauze, change every three days
and PRN;
-On 9/25/18, staff noted the resident has a Stage III pressure ulcer to his/her left
proximal gluteal (interior) area, which measured 1.2 cm by 0.8 cm by 0.1 cm. Resident also
had a Stage III pressure ulcer to his/her distal gluteal (exterior), which measured 0.8 cm
by 0.8 cm by 0.1 cm. Resident’s physician made aware. Small to moderate serosanguineous
drainage. treatment for [REDACTED].
-No information for the resident on the (MONTH) (YEAR) wound report information provided.
Review of the resident’s medical record, showed the following:
-A nurse’s note on 9/13/18 at 10:00 A.M., resident has an open area on his/her left
buttocks measuring 5 cm by 3.5 cy by 0.2 cm, moderate serosanguineous drainage noted to
the pink wound bed. Resident’s doctor informed and the wound treatment doctor informed to
see resident again. New order received: Cleanse left buttocks, apply border gauze every
three days and PRN;
-Review of the physician order [REDACTED].
-Review of the treatment administration record (TAR), dated 9/11/18 through 10/10/18,
showed staff documented administering this treatment as ordered;
-A wound care note, dated 9/25/18 at 8:31 A.M., by the wound treatment doctor. Measurement
for left gluteal proximal: 1.2 cm by 0.8 cm by 0.1 cm. Measurement for left gluteal
distal: 0.8 cm by 0.8 cm by 0.1 cm. Assessment: coccyx Stage III, recurrent. Plan:
Debridement (the removal of damaged tissue from a wound) with a curette (a surgical
instrument used to remove material by a scraping action). Treatment ordered: Apply Santyl
with silicone boarder gauze. Change dressing every three days and PRN. Offload pressure
areas and turn schedule per facility. Roho cushion (specialized pressure relief cushion
for wheelchairs) in wheelchair;
-On 9/25/18 at 9:10 A.M., Wound treatment doctor here to see resident. Open areas on
his/her left gluteal proximal area measuring 1.2 cm by 0.8 cm by 0.1 cm and left gluteal
distal measuring 0.8 cm by 0.8 cm by 0.1 cm. New order received for Santyl moistened onto
silicone coccyx dressing. Change every three days and PRN;
-Review of the POS [REDACTED]
-Staff did not include the order for the Roho cushion to the wheelchair;
-Review of the TAR dated 9/11/18 through 10/10/18, showed staff documented administering
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
the treatment as ordered. The TAR did not include an order for [REDACTED].>-Review of
the POS [REDACTED]. Apply to coccyx and gluteal proximal and distal. Staff drew a line
under the order and wrote no new orders 10/11/18;
-On 10/11/18 , no time given, a nurse’s note showed: Resident seen by wound treatment
doctor. Discontinue previous treatment. New orders: Start [MEDICATION NAME] moistened into
silicone border gauze, change every three days and PRN. Apply to coccyx and gluteal
proximal and distal;
-Review of the POS [REDACTED]
-Review of the TAR, dated 10/11/8 through 11/10/18, showed staff added the new order. The
Roho cushion could not be found on the TAR.
-Staff did not document providing the new treatment until 10/12/18 and did not document an
explanation;
-Staff did document the treatment every day from 10/12/18 thorough 10/16/18. Staff did not
document an explanation as to why the treatment was given every day;
-No further information was found in the nurse’s notes.
Observations of the resident, showed the following:
-On 10/11/18 at 3:22 P.M., the resident lay in his/her bed on a low air lost mattress
(pressure relieving mattress) on his/her left side. A Broda chair (specialized reclining
chair propelled by staff) was observed in the resident’s room without a Roho cushion;
-On 10/12/18 at 10:47 A.M. and 11:46 A.M., the resident sat up in his/her Broda chair in
the common area. A Roho cushion was not under the resident;
-Further observation of the resident on 10/12/18 at 12:53 P.M., showed he/she sat in a
Broda chair. The chair did not have a cushion. Certified Nurse Aide’s (CNA)’s F and G
transferred the resident to bed, and provided incontinence care. With Licensed Practical
Nurse (LPN) H present, CNA F removed the dressing from the coccyx and cleansed the
pressure ulcers with pre-moistened wipes wearing the same gloves he/she wore to provide
incontinence care;
-At 1:00 P.M., showed LPN H cleansed the pressure ulcers with wound cleanser and measured
the coccyx wound as 3.5 cm wide by 3.1 cm long. He/she staged the wound as a Stage III. A
second pressure ulcer located at the lower left buttock measured at approximately 0.25 cm
by 2.5 cm. He/she staged the wound as a stage II. LPN H applied a dry bordered gauze
dressing.
During an interview on 12/12/18 at 1:00 P.M., LPN H said nothing but the bordered gauze
dressing is used on the wound. The dressing is changed every three days and PRN.
Further observation of the resident, showed the following:
-On 10/15/18 at 9:00 A.M. and 11:27 A.M., the resident sat up in the common room in
his/her Broda chair without a cushion underneath. The resident sat in the same position;
-On 10/16/18 at 7:03 A.M. and 12:45 A.M., the resident sat up in the common room in
his/her Broda chair without a cushion underneath. The resident sat in the same position.
During an interview on 10/16/18 at 10:46 A.M., LPN E said the resident’s coccyx dressing
is changed every three days and PRN. He/she said the treatment to the wound consists only
of a bordered gauze dressing.
During an interview on 10/16/18 at 10:10 A.M, the Director of Nursing (DON) said it is
never permissible to cleanse a wound with a pre moistened cloth and especially with gloves
that have cleansed urine.
Further observation of the resident on 10/17/18 at 7:35 A.M., showed he/she sat up in the
common room in his/her Broda chair without a cushion underneath.
During an interview on 10/17/18 at 7:35 A.M., CNA J said the resident does not use a
cushion when up in his/her wheelchair. There is only the pad of the seat.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
During an interview on 10/17/18 at 8:30 A.M., the DON said she is responsible for
maintaining the weekly wound report. Wounds should be measured and documented every week.
She became aware of the resident’s coccyx wound on 10/10/18 when the wound treatment
doctor examined the resident. The new treatment should have started on 10/11/18. Staff
should provide treatments as ordered. If a treatment is given PRN, staff should document
why the treatment was given. A Roho cushion is a reasonable intervention to prevent
further worsening of a pressure ulcer. She did not know where the resident’s cushion was,
but said they could get one. The care plan should reflect the resident’s current care
needs and condition.
During an interview on 10/18/18 at 2:50 P.M., the wound treatment doctor’s nurse said she
is familiar with the resident and is present when the wound treatment doctor [MEDICATION
NAME] the resident. A Roho cushion was ordered on [DATE] and is a standard order they give
for residents with pressure ulcers like Resident #67’s. It is up to the facility to
implement the order. Without this cushion in place, the wound areas can become worse if
the resident is up in his/her chair and pressure is not being offloaded.

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain proper
placement of a supra pubic urinary catheter (a sterile tube inserted into the bladder
through the abdominal wall to drain urine) and failed to obtain physician orders
[REDACTED]. The facility identified one resident as having a supra pubic, or indwelling (a
sterile tube inserted into the bladder to drain urine) catheter. The resident was chosen
for the sample of 18 and problems were found this resident (Resident #130) The census was
82.
Review of the facility’s undated urinary catheter care policy, showed the following:
-Purpose, The purpose of this pocedure is to prevent catheter-associated urinary tract
infection;
-Maintaining Unobstructed Urine Flow, Check the resident frequently to be sure he or she
is not lying on the catheter and to keep the catheter and tubing free of kinks; the
urinary drainage bag must be held or positioned lower than the bladder at all times to
prevent the urine in the tubing and drainage bag from flowing back into the urinary
bladder;
-Infection control, Be sure the catheter tubing and drainage bag are kept off the floor.
1. Review of Resident #130’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 8/13/18, showed the following:
-Short and long term memory problems;
-Moderately impaired cognitive skills for daily decision making;
-Limited asssitance of staff required for most activities of daily living (ADL’s);
-Extensive assistance required for toilet use;
-Supra pubic (a sterile tube inserted into the bladder through the abdominal wall to drain
urine) catheter;
-Incontinent of bowel;
-[DIAGNOSES REDACTED].

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 19)
Review of the resident’s care plan, updated 8/10/18, showed the following:
-Problem, alteration in urinary function related to supra pubic catheter in use,
[DIAGNOSES REDACTED].};
-Goal, adequate urinary output and receive optimal care and management of catheter through
next review;
-Interventions, provide catheter care every shift, irrigate/change catheter per
physician’s orders [REDACTED].
-8/10/18 supra pubic catheter, continue to provide catheter care as directed, monitor for
signs and symptoms of infection and inform physician.
Review of the resident’s POS, dated 10/11/18 to 11/10/18, showed the following:
-An order, dated 9/30/18, to send the resident to the emergency room for evaluation;
-An order, dated 10/9/18, for [MEDICATION NAME]-clavulanate (antibiotic) 875-125
milligrams (mg), take one tablet twice daily with morning and evening medications for five
days;
-No order for supra pubic catheter, size, care or when to change the catheter.
Review of the resident’s nurse’s notes, showed the following:
-10/1/18, staff from the hospital called the facility to review the resident’s current
medications and reported the resident was admitted with possible urosepsis (Infection in
the bloodstream caused from urinary tract infection);
-10/9/18, resident returned to the facility via emergency medical technicians on a
stretcher, was admitted to hospital for urosepsis.
Observation of the resident showed the following:
-On 10/11/18 at 11:00 A.M. and 1:32 P.M., the resident lay in bed on his/her right side
with catheter tubing stretched taut from under the blanket, to underneath a wheelchair,
into a catheter privacy bag, with urine collected in the tubing unable to drain;
-On 10/11/18 at 3:45 P.M., the resident sat in a wheelchair in his/her room with catheter
tubing extended from the left pant leg to underneath the wheelchair, up and around, into
the catheter drainage bag. The tubing contained urine unable to drain in to the bag;
-On 10/12/18 at 12:16 P.M., the resident sat in a wheelchair at the dining room table and
fed him/herself lunch and no catheter tubing or drainage bag hung on the wheelchair;
-On 10/15/18 at 7:11 A.M., the resident lay in bed with the catheter drainage bag on the
floor, not in a privacy bag. At 8:28 A.M., a certified nurse aide (CNA) said the resident
wore a leg bag during the day;
-On 10/16/18 at 6:58 A.M., the resident lay in bed with the catheter draining bag not
contained in a privacy bag and the tubing extended from the resident, looped up and
around, and into the drainage bag, with urine in the bottom of the loop, unable to drain
into the bag;
-On 10/16 at 12:41 P.M., the resident sat in the television area in a wheelchair with the
catheter drainage bag contained in a privacy bag, and tubing came out of the pant leg,
looped up into the bag, with urine in the tubing unable to drain;
-On 10/17/18 at 7:33 a.M., the resident lay in bed with the catheter drainage bag on the
floor, not in a privacy bag and tubing looped up and into the catheter drainage bag with
urine in the tubing unable to drain. The drainage bag contained approximately 1200 cc’s of
yellow urine.
During an interview on 10/17/18, the Director of Nursing (DON) said there should be orders
on the POS for the resident’s catheter, including size, and instructions for care and
changing. The catheter drainage bag should be contained in a privacy bag and should never
touch the floor, for infection control purposes.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
used acceptable infection control procedures during perineal care (peri-care, surface area
between the thighs, extending from the pubic bone to the tail bone) for three of three
sampled residents (Resident #67, #44 and #63) and failed to sort and store soiled linen
which had the potential to affect all of the facility residents. The census was 82.
Review of the facility’s perineal care policy, revised (MONTH) (YEAR), showed rinse
perineum thoroughly using fresh water and a clean washcloth.
-The policy failed to instruct staff to use a new washcloth or new area of the wash cloth
for each area cleaned. The policy directed staff to rinse the washcloth in the clean
water, potentially contaminating the water.
Review of the facility’s hand washing policy, revised (MONTH) (YEAR), stated all personnel
shall follow policy and wash hands with soap and water, when hands are visibly soiled,
before and after direct contact with a resident, and before moving from a contaminated
body site to a clean body site during resident care.
1. Review of Resident #67’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 10/4/18, showed the following:
-Moderately impaired cognition;
-Dependent on staff for mobility and personal hygiene;
-Incontinent of bowel and bladder;
-[DIAGNOSES REDACTED].
Observation on 10/12/18 at 12:53 P.M., showed Certified Nurse Aide’s (CNA)’s F and G
entered the resident’s room. They washed their hands, donned gloves and transferred the
resident to bed. CNA F removed the resident’s wet with urine slacks and brief and provided
peri care. He/she then turned the resident to his/her left side which showed a foam
dressing to the coccyx, also wet with urine. He/she cleansed the urine from his/her
buttocks and with the same gloved hands removed the dressing and cleansed the wounds with
a pre-moistened cloth.
During an interview on 10/12/18 CNA F said when providing care to a resident it is
important to wash your hands before beginning and at the end of care. It is not necessary
to wash hands at any time in between. Even if something touched is dirty, it is not always
necessary to change gloves or even wash hands.
2. Review of Resident #44’s quarterly MDS, dated [DATE], showed the following:
-Moderate cognitive impairment;
-Extensive assistance required for mobility and dependent on staff for all personal
hygiene;
-Frequently incontinent;
-[DIAGNOSES REDACTED].
Observation on 10/12/18 at 6:44 A.M., showed CNA A entered the resident’s room and donned
gloves without washing his/her hands. He/she provided peri-care and washed his/her hands
and changed gloves. He/she then turned the resident to his/her left side, washed the
resident’s buttocks and applied barrier cream to the buttocks. Without washing his/her
hands or changing gloves, he/she dressed the resident and transferred him/her to the
wheelchair. CNA A then removed his/her gloves and without washing his/her hands applied
toothpaste to the toothbrush and handed it to the resident who began to brush his/her
teeth.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 21)
During an interview on 10/12/18 at 6:55 A.M., CNA A said it is important to wash your
hands when completely finished with care and not necessary any other time. He/she added
that if cleaning stool then gloves needed to be changed but not necessary to wash hands
and added it is only necessary to wash hands when completed with care.
3. Review of Resident #63’s quarterly MDS dated [DATE], showed total dependence for
toileting, personal hygiene, and total dependence for transfer from bed with [DIAGNOSES
REDACTED].
Observation on 10/15/18 at approximately 7:10 A.M., showed CNA B providing peri care to
the resident as he/she laid in bed. CNA B entered the resident’s room, washed his/her
hands with soap and water in the resident’s sink, filled the basin with water, placed the
basin on the bed side table and put on gloves. CNA A removed the resident’s urine soaked
brief and placed it in the trash bag. With the same gloved hands, he/she placed one clean
washcloth into the water basin, added soap onto the washcloth and began to cleanse the
resident’s peri area. CNA B then rinsed the soiled wash cloth with gloved hands in the
basin of water, used the same washcloth to cleanse the resident’s genitals. CNA B placed
the same soiled washcloth in the basin of water and with same gloved hands, grabbed a dry
towel and dried the resident’s peri area and genitals. With same gloved hands, CNA B
turned the resident to his/her side and used the same soiled washcloth from the water
filled basin and cleaned the resident’s backside. CNA B did not change his/her gloves nor
wash his/her hands. CNA B then used the same dry towel to dry off the resident’s backside.
CNA A then removed his/her gloves and washed his/her hands. He/she put on gloves and
applied barrier cream to the resident’s peri area and applied a clean brief. With same
gloved hands, CNA B placed a sheet on resident, gathered dirty linen in one hand, opened
the resident’s privacy curtain, opened door and exited resident’s room. CNA A returned to
the room with no gloves on and washed his/her hands. He/she took the basin of soiled
water, to the resident’s sink and dumped it down the sink drain.
During an interview on 10/15/18 at approximately 12:00 P.M., CNA B said he/she washed
his/her hands with soap and water before and after peri care is provided.
During an interview on 10/16/18 at 10:10 A.M., the Director of Nursing (DON) said when
providing personal care to a resident it is important to wash their hands as often as
possible and added, before providing care, after cleansing urine, after cleansing stool,
before dressing a resident and before touching anything in the room. She said it is never
permissible to cleanse a wound with a pre-moistened cloth especially with the same gloves
that cleaned urine.
4. Observation on 10/12/18 at approximately 11:27 A.M., of the north fifth floor shower
room, showed the following:
-A large bathtub with a sign that read out of order:
-Three trash bags of soiled linen in the bathtub;
-A pair of soiled sweat pants and a soiled towel in the bathtub;
-Three bags of trash on the ground.
Observation on 10/15/18 at approximately 12:05 P.M., showed a bag of soiled linen in the
bathtub of the north fifth floor shower room.
During an interview on 10/15/17 at 11:27 A.M., CNA C said the north fifth floor shower
room is not in use but staff does store dirty linen there. He/she added that linen should
be in the dirty clothes hamper and trash belongs in a trash can not on the ground.
5. Observation on 10/11/18 at 3:17 P.M., of the laundry room, showed the following:
-Four to five bags of clean bedding, in clear bags, on the ground under the laundry
sorting table;
-A large pile of soiled linen and clothes lay on the ground near the washing machines;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 22)
-Laundry aide D sorted the dirty clothes on the ground.
During an interview on 10/11/18 at 3:17 P.M., laundry aide D said, clothes and linen
should not be on the ground.
During an interview on 10/17/18 at 8:31 A.M., the DON and the administrator said, no
laundry should be on the ground nor in the bathtub. Soiled laundry should be kept in a
linen hamper and trash belongs in trash cans not on the ground.

F 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Make sure that the nursing home area is safe, easy to use, clean and comfortable for
residents, staff and the public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to keep the main dining room and
kitchen floors, walls, areas underneath and on piping, clean and in good repair, for five
of five days of the survey. The census was 82.
1. Observation of the kitchen on 10/11/18 at 10:26 A.M. and 4:52 P.M., 10/12/18 at 12:00
P.M., 10/15/18 at 10:15 A.M., 12:06 P.M. and 1:00 P.M., 10/16/18 at 1:12 P.M. and 10/17/18
at 8:00 A.M., showed the entire kitchen were streaked, with a dull, dirty appearance.
2. Observation of the main dining room on 10/16/18 at 8:30 A.M. and 12:16 P.M., showed the
following
-A large build up of dust, debris and dead bugs under a spider web which measured
approximately 12 high by 18 long extending from the lower middle portion of the wall in
the right corner on the north side of the dining room;
-A white/yellow grime at the cove base extending at least 12 under the window by the grand
piano;
-Debris built up along north wall around two radiators;
-A large brown dried liquid spill and a red wash cloth on floor next to TV;
-White and rust colored grime on the tiles and below the pipes on east wall by kitchen;
-Two pipes with greenish paint chips and rust approximately 6 feet from residents tables
along the south wall;
-A build up of debris and dust in the corner outside dietary managers office;
-Approximately 2 feet of cove base pulling away from wall at door of storage room;
-Debris, spider webs and dead c[DIAGNOSES REDACTED] under the horizontal pipes and
radiator along the east wall;
-Dust build up on all the pipes, either at the joints of vertical pipes or on the tops of
horizontal pipes.
3. During an interview on 10/16/18 12:28 P.M., the Dietary Manager said it is the dietary
department’s responsiblility to clean the floors and the dining room. It is apart of the
detailed cleaning that should be done every day. It is an assigned task for dietary aides,
and they are responsible to make sure they do their work.
Review of the daily cleaning duties list provided by the facility on 10/16/18 at
approximately 12:30 P.M., showed the following:
-Sweep dining room;
-Mop kitchen and dining room floors.
4. During an interview on 10/17/18 at 8:30 A.M., the Administrator said the kitchen floor
is not that old and is hard to take care of. Stripping and waxing would probably not help
that much.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/12/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265668

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

10/17/2018

NAME OF PROVIDER OF SUPPLIER

CARRIE ELLIGSON GIETNER HOME

STREET ADDRESS, CITY, STATE, ZIP

5000 SOUTH BROADWAY
SAINT LOUIS, MO 63111

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0924

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Put firmly secured handrails on each side of hallways.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain 18 hand rails in good
repair or firmly affixed to the wall on the first, second, third and fourth floor of the
facility. This practice potentially affected any residents who reside in or use those
areas in the facility. The facility census was 82 residents.
Observations of the facility on 10/15/18 from 1:25 P.M. until 2:00 P.M., showed the
following:
-On the first floor a loose hand rail outside room [ROOM NUMBER] and a hand rail with the
bolt out of the wall across from the nurse’s station;
-On the second floor a loose hand rail outside room [ROOM NUMBER] and across from rooms
[ROOM NUMBERS];
-On the third floor loose hand rails outside of rooms 300, 302, 319, 333 and across from
333 by the smoke door;
-On the fourth floor, loose hand rails outside of the stair well going up to 5th floor on
both sides of stairwell and on the rail directly across from the doorway to the 400 hall.
Loose hand rails were observed outside rooms [ROOM NUMBERS] and across from room [ROOM
NUMBER], on the opposite wall between rooms [ROOM NUMBERS] and next to the linen closet
before room [ROOM NUMBER].
During an interview on 10/16/18 at 8:34 A.M., the maintenance director said he frequently
checks the hand rails throughout the building. The last time they were checked was about a
week ago. They become loose often due to residents pulling on them. He does not keep a log
to monitor how often they are tightened, it is just apart of routine building maintenance.

During an interview on 10/17/18 at 8:30 A.M., the administrator said the hand rails are
checked every couple of weeks and tightened. The first floor is the worst. They do not
keep a log.