5 CMS Surveys
Inspection Report — Jun 5, 2025
Complaint Investigation
Date: Jun 5, 2025
Visit Reason
The investigation was prompted by an allegation of theft of money from a resident's purse.
Complaint Details
The cited finding concerns the facility's inadequate investigation of a theft allegation involving resident #34, including failure to interview other residents or witnesses and incomplete reimbursement.
Findings
The facility failed to fully investigate the theft allegation involving resident #34, reimbursing only part of the missing money and not interviewing other residents or potential witnesses. Law enforcement was notified but did not pursue the case further.
Deficiencies (1)
F 0610 Respond appropriately to all alleged violations: the facility did not fully investigate the theft allegation of money from resident #34's purse, failing to interview other residents or potential witnesses and only reimbursing $100 of the missing amount.
Report Facts
Residents sampled: 21
Money missing ($): 300
Money reimbursed ($): 100
People in and out of room: 50
Date of initial report: 4.08
Inspection Report — Jun 5, 2025
Renewal
Date: Jun 5, 2025
Visit Reason
The survey was a renewal inspection to assess compliance with licensing standards and ensure resident safety and care quality.
Findings
The facility had multiple deficiencies including failure to inform residents about psychotropic medication risks, inadequate investigation of theft allegations, incomplete care plan updates after falls and infections, insufficient pressure ulcer care, lack of individualized fall prevention strategies, absence of dialysis policies and monitoring, and poor infection control practices including hand hygiene and equipment sanitation.
Deficiencies (7)
F 0552 Ensure that residents are fully informed and understand their health status, care and treatments: the facility failed to document that the resident and representative were informed of risks and benefits of psychotropic medications prior to treatment.
F 0610 Respond appropriately to all alleged violations: the facility failed to fully investigate a theft allegation, did not interview potential witnesses or other residents, and did not determine if others were affected.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to review and revise care plans for three residents, missing updates after catheter removal, falls, and urinary tract infection resolution.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to provide necessary treatment and repositioning for two residents, contributing to chronic Stage II and Stage III pressure ulcers.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to identify root causes of falls and implement individualized fall prevention strategies for a resident with multiple unwitnessed falls.
F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services: the facility lacked policies, contracts, and monitoring for dialysis care and transportation for a resident receiving dialysis.
F 0880 Provide and implement an infection prevention and control program: the facility failed to maintain proper hand hygiene during medication passes, maintain cleanable surfaces on floor mats and respiratory equipment, and properly store tube feeding supplies, increasing infection risk.
Report Facts
Residents sampled: 21
Residents with pressure ulcers sampled: 7
Residents with respiratory equipment sampled: 6
Residents with medication passes observed: 7
Dialysis resident sampled: 1
Pressure ulcer measurements (cm): 13.5
Pressure ulcer measurements (cm): 9
Braden Scale score: 10
Falls documented: 4
Inspection Report — Jul 2, 2024
Renewal
Date: Jul 2, 2024
Visit Reason
Routine renewal inspection of Gallatin Rest Home to assess compliance with health and safety regulations.
Findings
The facility failed to provide meals with no more than 14 hours between dinner and breakfast, did not offer nourishing bedtime snacks, and lacked documentation of resident group approval for mealtime hours. Additionally, the facility did not fully implement or document its Legionella prevention water management plan and maintained an unclean ice/water dispenser.
Deficiencies (2)
F 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests: the facility allowed a 15-hour gap between dinner and breakfast, did not provide nourishing bedtime snacks, and lacked documentation of resident group approval for mealtime hours.
F 0880 Provide and implement an infection prevention and control program: the facility failed to fully implement and document its water management plan to prevent Legionella growth and maintained an ice/water dispenser with uncleanable surfaces and visible contamination.
Report Facts
Hours between dinner and breakfast: 15
Residents sampled: 13
Residents affected: 7
Years staff member H employed: 14
Inspection Report — Jun 8, 2023
Renewal
Date: Jun 8, 2023
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with licensing requirements.
Findings
The facility failed to protect a resident from verbal abuse by a staff member and did not thoroughly investigate the alleged abuse. The abusive staff member's contract was terminated, but documentation of interviews with other residents was not provided.
Deficiencies (2)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect one resident from verbal abuse by a staff member who refused to assist with bathroom needs and yelled at the resident, causing psychosocial harm.
F 0610 Respond appropriately to all alleged violations: the facility failed to thoroughly investigate an alleged verbal abuse incident, lacking documentation of interviews with other residents who may have been affected.
Report Facts
Residents affected: 1
Residents sampled: 4
Inspection Report — Jun 8, 2023
Renewal
Date: Jun 8, 2023
Visit Reason
Routine renewal inspection of Gallatin Rest Home to assess compliance with health, safety, and quality standards.
Findings
The facility failed to protect a resident from verbal abuse by staff, did not thoroughly investigate abuse allegations, and failed to maintain equipment leading to a resident fall. Additionally, kitchen staff did not follow proper hair and beard covering protocols, food items were not properly labeled or dated, hand hygiene was not consistently performed during meal service, and the facility lacked ongoing quality improvement projects related to abuse prevention.
Deficiencies (6)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect: the facility failed to protect one resident from staff verbal abuse, causing psychosocial harm and feelings of vulnerability.
F 0610 Respond appropriately to all alleged violations: the facility failed to thoroughly investigate an alleged abuse incident and did not document resident interviews related to the abuse.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to maintain chair scale equipment, resulting in a resident fall with a 12 cm laceration requiring sutures.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: kitchen staff failed to wear proper hair and beard coverings and failed to label and date food items in the freezer, risking foodborne illness.
F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action: the facility failed to perform annual performance improvement projects and did not involve QAPI in abuse system issues.
F 0880 Provide and implement an infection prevention and control program: staff failed to perform hand hygiene when delivering and setting up meal trays for residents, risking infection transmission.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Sutures: 20
Residents affected: 18
Food items not dated: 5
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