Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Advanced Care Of St Joseph during CMS and state inspections, most recent first.
Two residents were moved to different rooms multiple times without receiving written notification or the opportunity to participate in the decision, despite their care plans and diagnoses of anxiety and depression. Family members were also not informed in writing, and the facility lacked a consistent process for notifying residents or families about room changes.
Surveyors found that a resident did not receive appropriate care for continence or incontinence, including improper catheter care and insufficient measures to prevent UTIs. These lapses resulted in a deficiency related to the standard of care for residents with bowel and bladder needs.
A resident dependent on staff for hygiene, with cognitive and communication deficits, was repeatedly observed with significant facial hair and dried food on the face. The care plan did not address facial hair management, and the resident expressed a desire for hair removal. Staff were unaware of the issue, resulting in a failure to uphold the resident's dignity and personal preferences.
Residents were not given the opportunity or support to organize and participate in resident or family groups, as required. The facility did not facilitate or respect the formation and participation of these groups.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish a grievance policy or make prompt efforts to resolve complaints.
Three residents with cognitive and physical impairments did not consistently receive scheduled or preferred showers, as required by their care plans and facility policy. Staff interviews and documentation confirmed that showers were missed, leading to resident discomfort and dissatisfaction. The lack of a designated shower aide and reliance on available aides contributed to the inconsistency in providing necessary hygiene care.
Surveyors found that staff failed to discard expired leftovers, did not wear required beard nets, and did not maintain cleanliness in the walk-in refrigerator. Food carts delivered to residents had uncovered desserts and drinks, with some food items exposed to contamination and trays with spilled liquids. The cleaning schedule was incomplete, and management confirmed that these practices did not meet facility expectations.
A resident with a history of falls and on anticoagulant medication reported a fall to an RN, who failed to initiate neurological assessments. CNAs found the resident on the floor but did not notify a nurse before assisting the resident back to bed, contrary to protocol. The resident later showed increased confusion and a fractured collar bone, leading to hospitalization. The facility did not document the fall, and staff interviews confirmed protocol breaches.
The facility failed to administer medications and treatments timely and accurately for several residents, leaving blanks in the MAR and TAR. A resident with severe cognitive impairment and heart conditions experienced significant delays in medication administration. Another resident with multiple sclerosis and pressure ulcer risk had undocumented treatments, and a third resident with heart failure and diabetes had missed medication entries. Staff interviews confirmed these practices were not standard.
The facility failed to maintain a proper accounting system for residents' personal funds, with missing statements for six months and discrepancies in petty cash balance. The BOM, new to the position, noted the absence of records due to ownership changes. Additional receipts revealed a surplus attributed to a slush fund, contrary to proper practices.
The facility failed to store dry foods in sealed containers, risking pest contamination for 128 residents. Observations revealed unsealed breadcrumb bags and improperly closed cereal containers, confirmed by the DM, Registered Dietician, and Maintenance Supervisor. The facility's sanitation policy was not followed.
The facility failed to maintain an effective pest control program, with multiple sightings of mice and cockroaches in various areas, including the kitchen and nurses' stations. Observations revealed potential access points for pests, such as a hole in the storage room and gaps under doors. Despite documented sightings, the Administrator believed the issue had been resolved, indicating a lack of effective measures to address the pest control issues.
The facility failed to provide adequate respiratory care for four residents, with deficiencies in equipment maintenance and storage. A resident lacked a physician order for cipap use, and equipment was dusty and improperly stored. Another resident's oxygen rate was incorrect, and equipment was outdated and unclean. Two more residents had issues with nebulizer equipment maintenance. Staff interviews revealed confusion about responsibilities and a lack of clear procedures for maintaining respiratory equipment.
The facility failed to implement proper infection control measures, resulting in psychosocial harm to a resident with scabies due to lack of isolation. Additionally, several residents with MDROs were not placed on Enhanced Barrier Precautions, and staff did not follow hand hygiene protocols during meal service, leading to lapses in infection control.
A resident with severe cognitive impairment was transferred to the ER without a written transfer notice being provided to them or their representative. The facility's SSD later admitted to printing new notices and obtaining signatures days after the transfer, indicating a lapse in protocol.
A resident was transferred to the ER without receiving written notification of the bed hold policy, as required. The facility's Administrator and Social Services Director could not provide evidence that the policy was communicated at the time of transfer, leading to a deficiency in procedure.
A facility failed to accurately code the MDS for a resident in hospice care, as revealed by a review of records and interviews. The resident, who was severely cognitively impaired, was not coded for hospice in the MDS Section O. The MDS Coordinator acknowledged the oversight, and the DON confirmed that MDS responsibilities are managed by the MDS Coordinator. The facility's policy requires a Significant Change in Status Assessment for hospice enrollment, which was not followed.
The facility failed to complete a Level 1 PASARR for two residents with mental health diagnoses, as confirmed by the Business Office Manager and Administrator. The residents' electronic medical records lacked the required documentation, indicating non-compliance with PASARR requirements.
A resident with a skin condition and self-isolation was not provided with a comprehensive care plan addressing her scabies treatment, sores, self-perception, or mental health. Despite being cognitively intact and receiving treatment for itching, her care plan only noted blisters related to fluid retention. Interviews with the ICP and DON confirmed that a care plan should have been generated.
A facility failed to document behavior monitoring for a resident on psychotropic medications, contrary to its policy requiring such documentation to demonstrate medication benefits. Interviews revealed that while side effects were monitored, behavior monitoring was not documented. The administrator acknowledged the oversight, noting that behavior monitoring should have been identified in meetings.
A facility failed to secure medications properly, with two vials of albuterol sulfate found at a resident's bedside without a self-administration order, and 17 insulin pens left unattended on a medication cart. Both the DON and Administrator confirmed that medications should be stored securely, highlighting a breach in the facility's medication storage policy.
The facility did not update the daily nurse staffing information, leaving outdated postings visible for several days. The responsibility for updating the staffing sheet was shared between the Staff Schedule Coordinator during weekdays and the weekend manager or charge nurse on weekends. However, the absence of a company policy on posting the daily staffing sheet contributed to this oversight.
A facility failed to enforce its drug-free policy, leading to repeated drug use incidents in a shared room. One resident, with a history of substance abuse, was found unresponsive multiple times, requiring Narcan. The roommate, with severe cognitive impairment, alerted staff but was not protected from potential exposure. Despite staff concerns, the facility did not implement effective safety measures, citing residents' rights.
Failure to Provide Written Notification and Choice for Room Changes
Penalty
Summary
The facility failed to protect the rights of two residents by not providing written notification of room changes to them or their family members, as required by facility policy. Both residents had care plans indicating the right to be fully informed in advance of any room or roommate changes and to participate in decision-making, especially given their diagnoses of anxiety, depression, and other medical conditions. Despite this, one resident experienced six room changes in six weeks without written notice or the opportunity to decline, resulting in emotional distress. The resident's family member, who was the responsible party, also reported not being notified or consulted about at least five of these moves. Another resident was moved to a different room without consent, despite expressing a desire not to move and not wanting a new roommate. The move was executed while the resident was at lunch, and belongings were relocated without the resident's participation. The Social Services Director confirmed that written notifications were not provided, and there was no established policy or process for room change notifications. Notification practices were inconsistent, sometimes occurring only a few hours before the move, and records of written notices were not maintained.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These deficiencies were observed through direct surveyor findings, indicating lapses in the standard of care required for residents with these needs.
Failure to Address Resident's Facial Hair and Hygiene Needs
Penalty
Summary
A resident with a history of stroke, diabetes, impaired cognition with communication deficit, and dementia was dependent on nursing staff for all hygiene care and unable to perform these tasks independently. The resident's care plan acknowledged the right to dignity but did not address the management of facial hair by nursing staff. Multiple observations over several days documented the resident sitting in the dining room with facial hair greater than one inch on the upper lip, around the mouth, chin, and extending down the neck. On one occasion, dried food from a previous meal was noted on the outside of the resident's mouth and facial hair. During interviews, the resident expressed a desire to have the facial hair removed, stating that it was bothersome. A CNA reported being unaware of the unwanted facial hair and indicated that shaving should occur during showers or as needed. The DON confirmed that residents who do not wish to have unwanted facial hair can be shaved by nursing staff on shower days and as needed. The lack of attention to the resident's facial hair and hygiene needs, as well as the omission in the care plan, resulted in a failure to honor the resident's right to dignity and self-determination.
Failure to Honor Resident Rights to Organize and Participate in Groups
Penalty
Summary
The facility failed to honor the right of residents to organize and participate in resident and family groups. This deficiency was identified when it was observed that residents were not provided the opportunity or support to form or participate in such groups within the facility. The report notes that the facility did not facilitate or respect the organization and participation of these groups as required.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. Additionally, the facility did not establish a grievance policy or make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address and resolve resident complaints in a timely and non-retaliatory manner.
Failure to Provide Timely Showers and Maintain Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for three residents who required assistance with activities of daily living, specifically bathing and showering. Observations, interviews, and record reviews revealed that these residents did not consistently receive showers as scheduled or preferred, despite facility policies requiring showers to be provided per resident request or facility schedule. For example, one resident received only one shower in June despite being eligible for five, and another received only four out of eight required showers in June. Documentation and interviews with staff and residents confirmed that showers were missed, and residents expressed discomfort and dissatisfaction with the infrequency of bathing. The affected residents had varying degrees of cognitive and physical impairment, with diagnoses including cancer, heart failure, diabetes, depression, and anxiety disorder. Care plans indicated the need for staff assistance with bathing and specified the frequency and method of bathing, such as sponge baths when showers could not be tolerated. Staff interviews revealed a lack of a designated shower aide and reliance on available aides to provide showers, which contributed to the inconsistency. Residents reported feeling unclean and uncomfortable due to missed showers, and staff acknowledged complaints and the expectation that residents should receive showers according to their preferences and care plans.
Deficiencies in Food Storage, Preparation, and Service Standards
Penalty
Summary
Surveyors identified multiple failures in food storage, preparation, and service within the facility's dietary department. Staff did not discard expired leftovers in the refrigerator, with items such as sauerkraut, sliced onions, and cheese found past their expiration dates, and some containers were not properly sealed. The walk-in refrigerator was observed to have moldy fruit and butter containers on the floor, significant dirt and grime in a corner, black grime along the base of the wall, and heavy rust on shelving support rods. The weekly cleaning schedule was incomplete, with only two assignments documented for the first week of the month and no cleaning assignments posted for the following month. Additionally, a dietary aide was observed working at the dishwashing station on multiple occasions without a required beard net, despite having a full beard. During meal service, food carts delivered to resident halls had uncovered desserts and drinks, with the plastic covering the cart touching exposed food items. Several trays had spilled liquids from uncovered drink cups, resulting in dampened napkins and utensils. Interviews with dietary management and the administrator confirmed that staff were expected to wear beard nets, maintain a posted and completed cleaning schedule, discard leftovers after seven days, and cover drinks and desserts during tray delivery. However, these practices were not consistently followed, as evidenced by the observations and staff interviews.
Failure to Conduct Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to complete necessary neurological assessments for a resident after an unwitnessed fall was reported. The resident, who had a history of falls and was on anticoagulant medication, reported to an RN that they had fallen the previous night and had been picked up off the floor by someone. Despite the resident showing signs of increased confusion and having visible bruises, the RN did not initiate the required neurological assessments as per the facility's head injury policy. Additionally, the facility's CNAs did not follow protocol when they found the resident on the floor. Instead of notifying the nurse immediately, they assisted the resident back to bed without a nurse's assessment. This action was contrary to the facility's fall policy, which requires a nurse to assess the resident before repositioning them after a fall. The CNAs later informed the charge nurse of the incident, but the delay in reporting and the lack of immediate assessment contributed to the deficiency. The resident's condition worsened, with increased confusion and a fractured collar bone discovered later. The facility staff failed to document the fall on the night it occurred, and the resident was eventually sent to the hospital. Interviews with the facility's staff, including the DON and the Administrator, confirmed that the expected protocols for handling unwitnessed falls and conducting neurological assessments were not followed, leading to the deficiency.
Medication and Treatment Administration Deficiencies
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice, as evidenced by the failure of licensed nursing staff to ensure that physician's orders were carried out for three of five sampled residents. Medications were not administered timely for these residents, and there were blanks left in the medication administration record (MAR) and treatment administration record (TAR) for two residents. The facility's policies required that medications and treatments be administered as ordered by the physician and documented appropriately, but these standards were not met. Resident #1, who was severely cognitively impaired and had multiple diagnoses including coronary artery disease and heart failure, experienced significant delays in medication administration. For instance, medications scheduled for 7:00 A.M. were often administered hours later, sometimes as late as 2:18 P.M. This resident's care plan required medications to be given as ordered to manage conditions such as depression and hypertension, but the facility failed to adhere to these orders consistently. Resident #4, who was cognitively intact but had multiple sclerosis and was at risk for pressure ulcers, also experienced issues with medication and treatment administration. There were multiple instances where medications and wound care treatments were not documented as administered, leaving blanks in the MAR and TAR. Similarly, Resident #5, who had heart failure and diabetes, had several instances of missed or undocumented medication and treatment administrations. Interviews with facility staff, including LPNs and RNs, confirmed that leaving blanks in the MAR and TAR was not standard practice, indicating a systemic issue with documentation and adherence to physician orders.
Deficiency in Resident Personal Funds Management
Penalty
Summary
The facility failed to maintain a proper accounting system for residents' personal funds, as evidenced by the lack of available personal funds statements for six out of twelve months reviewed from June 2023 to November 2023. The business office manager (BOM) was unable to provide a policy or explanation for the discrepancies in the petty cash balance, which was off by $59.09 during an observation. The BOM, who started employment in December 2023, noted that the position had been vacant for two months prior and that the facility had undergone two ownership changes, which contributed to the lack of records. Further observations revealed additional receipts, leading to a surplus of $204.06 in petty cash, which the BOM attributed to a facility slush fund. The administrator confirmed that the facility was taken over by a new company on June 1, 2023, and that previous records were maintained on paper by the prior owner. The administrator also stated that there should not be a slush fund and that petty cash should balance with cash on hand and receipts, indicating a failure in maintaining proper accounting practices.
Deficiency in Food Storage Practices
Penalty
Summary
The facility failed to ensure that dry foods were stored in sealed containers, compromising food freshness and protection from pests for all 128 residents who received food prepared in the kitchen. During an initial tour of the kitchen, two 25-pound bags of breadcrumbs were found in a small storage room, with one bag open to air, undated, and unsealed, and the other unopened. Both bags were made of paper and not stored in sealed containers, making them susceptible to insects, pests, or rodents. Additionally, three 18-gallon plastic containers with dry cereal were observed with lids that could not be closed properly, allowing potential access for pests. The observations were confirmed by the Dietary Manager (DM) during the initial tour and again during a second tour, where the same issues with the cereal containers were noted. The DM, along with the Registered Dietician and the Maintenance Supervisor, confirmed the observations during the second tour. The DM acknowledged understanding the concerns during an interview. The facility's policy on sanitation inspection, dated 09/01/21, emphasizes the need for food service areas to be clean, sanitary, and compliant with state and federal regulations, which was not adhered to in this instance.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program across multiple areas, including five of six halls, two nurses' stations, shower rooms, the therapy room, and the kitchen, which includes the dish room area. The facility's policy, dated 09/01/21, outlined the need for an effective pest control program to eradicate and contain common household pests and rodents. However, during an initial tour of the kitchen, a hole was observed behind the cove base in the small storage room, creating potential access for pests. Additionally, a mouse dropping was found on a container of powdered sugar, which was stored above unsealed containers of dry cereal. Gaps were also noted at the bottom of doors leading from the dry storage room and the hallway across from the kitchen, providing further access points for pests. The facility's pest control contract included routine pest control and spot service for specific concerns, as noted on the Pest Sighting/Evidence Log. This log revealed multiple sightings of mice and cockroaches in various areas, including the nurses' stations, kitchen, dish room, and several halls, from January to June 2024. Despite these documented sightings, the Administrator acknowledged awareness of the issue but believed it had been resolved. The observations were confirmed by the Dietary Manager, Registered Dietician, and Maintenance Director, indicating a lack of effective measures to address the pest control issues as per the facility's policy.
Inadequate Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate respiratory care for four residents, as observed through various deficiencies in the handling and maintenance of respiratory equipment. For Resident 62, there was no physician order for the use of a cipap machine, and the equipment was found to be dusty and improperly stored. The Director of Nursing confirmed the lack of a physician order, and the resident's cipap mask was observed uncovered and unbagged, contributing to potential infection control issues. Interviews with staff revealed a lack of awareness and procedures for cleaning and maintaining cipap and bipap equipment. Resident 24's oxygen rate was not set according to the physician's order, and the equipment was similarly found to be dusty and improperly maintained. The resident's oxygen tubing was outdated, and the nebulizer mask was left uncovered. Interviews with staff indicated confusion about responsibilities for cleaning and maintaining respiratory equipment, with some staff unaware of who was responsible for these tasks. The Director of Nursing acknowledged the lack of a specific policy for cleaning and maintaining respiratory equipment, relying instead on manufacturer guidelines. Residents 45 and 53 also experienced deficiencies in respiratory care. Resident 45's nebulizer chamber contained liquid, and the oxygen concentrator filter was clogged with dust, indicating a lack of proper maintenance. Resident 53's nebulizer equipment was left unbagged with liquid residue, and staff interviews confirmed that the equipment was not cleaned and stored as required. The facility's policies and staff interviews highlighted inconsistencies and a lack of clarity in the procedures for maintaining respiratory equipment, contributing to the observed deficiencies.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an appropriate infection control program for several residents, leading to psychosocial harm for one resident. Specifically, the facility did not follow its policy for isolation during treatment for scabies for a resident, who was not placed on contact isolation during multiple treatments in March, April, and May. The resident, who was cognitively intact, experienced severe itching and distress, and the facility's staff, including the Infection Control Preventionist (ICP) and Maintenance Supervisor, were not adequately informed or involved in the isolation and cleaning procedures. The resident's room and belongings were not properly cleaned or isolated, and the resident continued to suffer from symptoms without proper isolation measures being implemented. Additionally, the facility did not adhere to its Enhanced Barrier Precautions (EBP) policy for residents with multidrug-resistant organisms (MDROs). Several residents with chronic wounds and positive cultures for MRSA and other organisms were not placed on EBP, and staff were observed not wearing personal protective equipment (PPE) during high-contact care activities. The ICP provided a list of residents needing EBP, but the facility failed to implement these precautions, and the Administrator was unaware of the residents with positive cultures. Furthermore, the facility did not follow appropriate hand hygiene practices during meal service. Staff, including the Medical Records Supervisor and Certified Nurse Aides, were observed not performing hand hygiene between delivering meal trays to residents' rooms. Despite training and expectations set by the facility, there was no specific policy addressing hand hygiene during meal service for nursing staff, leading to lapses in infection control practices.
Failure to Provide Timely Transfer Notice
Penalty
Summary
The facility failed to provide a written transfer notice to a resident and their resident representative during an emergent hospital transfer. The resident, who was severely cognitively impaired with a BIMS score of four out of 15, was transferred to the emergency room on the order of the hospice medical director due to concerns of a bowel obstruction. The transfer occurred without the required written notice being documented in the electronic medical record. Interviews with the facility's Administrator and Social Services Director (SSD) revealed that the written transfer notices were not initially available. The SSD admitted to printing new notices and obtaining the resident representative's signature only on the day of the interview, which was several days after the transfer. There was no evidence to show that the resident or their representative received the written notice at the time of the transfer, indicating a lapse in the facility's protocol for notifying residents and their representatives about transfers.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a resident or their representative with written notification of the bed hold policy prior to the resident's transfer to the hospital. This deficiency was identified during a review of the resident's records and interviews with facility staff. The resident, who was severely cognitively impaired, was transferred to the emergency room for evaluation due to a suspected bowel obstruction. However, there was no documentation in the electronic medical record indicating that the bed hold policy was communicated to the resident or their representative at the time of transfer. During an interview, the facility's Administrator acknowledged the absence of the bed hold documentation, which was typically kept in a designated folder. The Social Services Director later provided a document with the resident's name and a date, but it was revealed that the signatures were obtained only after the incident, and no original documentation could be found. This lack of documentation and timely communication of the bed hold policy constituted a deficiency in the facility's procedures.
Failure to Accurately Code MDS for Hospice Care
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident, identified as Resident 37, who was reviewed for MDS accuracy. The deficiency was identified through a review of records, interviews, and policy review, which revealed that the MDS for Resident 37 did not indicate hospice care, despite the resident being in a hospice program. The resident's annual MDS assessment showed a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating severe cognitive impairment. However, the MDS Section O, which covers Special Treatments, Procedures, and Programs, did not reflect the resident's hospice status. Interviews conducted during the investigation revealed that the MDS Coordinator acknowledged the oversight, stating that the MDS did not indicate hospice care and that there were issues when they assumed their role in November. The Director of Nursing (DON) confirmed that they do not handle MDS responsibilities, which are managed by the MDS Coordinator. The facility's policy on MDS 3.0 Completion requires a Significant Change in Status Assessment (SCSA) when a resident enrolls in a hospice program or changes hospice providers, which was not adhered to in this case.
Failure to Complete Level 1 PASARR for Two Residents
Penalty
Summary
The facility failed to ensure that a Level 1 Pre-Admission Screening and Resident Review (PASARR) was completed for two residents, identified as R22 and R60, who were reviewed for PASARR compliance. R22 was admitted with diagnoses of major depressive disorder, schizoaffective disorder, and anxiety, while R60 was admitted with bipolar disorder and schizoaffective disorder. Upon review of their electronic medical records, it was found that there was no documentation of a Level 1 PASARR having been completed for either resident. During interviews, the Business Office Manager confirmed that the Level 1 PASARR documentation could not be found in the records of R22 and R60, acknowledging that it should have been present. The Administrator also stated that a Level 1 PASARR was expected to be in the residents' records, indicating a lapse in the facility's compliance with PASARR requirements.
Failure to Develop Comprehensive Care Plan for Resident with Scabies
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R61, who was at risk for unmet psychosocial needs due to a skin condition and subsequent self-isolation. The facility's policy requires a comprehensive person-centered care plan for each resident, including measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. However, R61's care plan did not address her scabies treatment, sores on her chest, back, arms, and trunk, self-isolation, self-perception, or mental health. This oversight was identified through observation, interviews, and record reviews. R61, who was cognitively intact with a BIMS score of 14 out of 15, reported having scabies for two to three months and expressed severe discomfort due to itching. Despite receiving treatment with permethrin cream and Hydroxyzine HCL for itching, her care plan only noted blisters related to fluid retention on her left lower extremity, with interventions to avoid scratching and keep fingernails short. Interviews with the Infection Control Preventionist and the Director of Nursing confirmed that a care plan should have been generated to address these issues.
Lack of Behavior Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to provide documentation of behavior monitoring for the continued use of an antipsychotic medication for a resident reviewed for unnecessary medications. The facility's policy on the use of psychotropic drugs requires that residents are not given such medications unless necessary to treat a specific condition, and the medication's benefits must be demonstrated through monitoring and documentation of the resident's response. However, for the resident in question, there was no order to monitor or document behaviors related to the use of psychotropic medications, which included Aripiprazole, Buspirone, Fluoxetine, and Hydroxyzine. Interviews with facility staff revealed that while side effects of psychotropic medications were monitored, there was no documentation of behavior monitoring. A registered nurse indicated that unusual behaviors would be charted in progress notes, but no such documentation was found. The facility administrator acknowledged that behavior monitoring should have been identified during morning meetings, and there should have been an order for behavior monitoring related to the use of psychotropic medications.
Medication Storage Deficiency
Penalty
Summary
The facility failed to adhere to its medication storage policy, which mandates that all drugs and biologicals be stored in locked compartments. During an observation, two full vials of albuterol sulfate were found next to a nebulizer machine in a resident's room. The resident, identified as R26, did not have a physician's order to self-administer the medication, nor was there any documentation of a self-administration assessment in the electronic medical record (EMR). This oversight was confirmed by a registered nurse, who acknowledged that medications should not be at the bedside. Additionally, during an inspection of the medication cart, 17 insulin pens were found on top of the cart, unattended, while the responsible nurse was away from the area. The Director of Nursing confirmed this observation and stated that medications should be stored in the cart and not left on top or at the resident's bedside. The facility's administrator also expressed that medications should not be left at the bedside or on top of the medication cart, indicating a clear deviation from the facility's established medication storage protocols.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted and available for residents, families, and visitors. Observations on three separate occasions revealed that the staffing information posted was outdated, displaying the staffing details from 06/17/24, despite being observed on 06/18/24, 06/19/24, and 06/20/24. Interviews with the Staff Schedule Coordinator and the Administrator confirmed that the responsibility for updating and posting the staffing sheet was divided between the coordinator during weekdays and the weekend manager or charge nurse during weekends. However, the Human Resource Specialist noted that there was no company policy regarding the posting of the daily staffing sheet, contributing to the oversight.
Failure to Prevent Drug Use in Shared Room
Penalty
Summary
The facility failed to operationalize its Illegal Drug Use policy, resulting in a hazardous environment for two residents sharing a room. Staff repeatedly found illegal drugs and drug paraphernalia in the room, yet no effective measures were implemented to prevent these occurrences. Despite being aware of the situation, the facility leadership did not provide adequate direction or supervision to ensure the safety of the residents. The facility's policy stated that it was a drug-free environment, but the lack of enforcement and supervision led to repeated incidents of drug use by one of the residents. One resident, who had a history of substance abuse, was found unresponsive multiple times due to drug overdoses, requiring the administration of Narcan. The resident's roommate, who had severe cognitive impairment and a history of drug abuse, was the one who alerted staff to these emergencies. Despite the roommate's distress and the potential risk of accidental exposure to drugs, the facility did not implement additional safety measures or notify the roommate's guardian about the presence of drugs in the room. Interviews with staff revealed that they were aware of the drug use and had reported their concerns to the facility's administration, but no significant changes were made to address the issue. The facility's leadership acknowledged the problem but cited residents' rights as a reason for not conducting searches or implementing stricter supervision. The lack of a comprehensive plan to prevent drug use and ensure resident safety contributed to the ongoing risk and repeated incidents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Joseph
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Joseph Chateau | 1.3 mi | ★★★★★ | 2 | 0 |
| St Joseph Manor Health & Rehabilitation | 2 mi | ★★★★★ | 2 | 0 |
| Carriage Square Rehab And Healthcare Center | 2.3 mi | ★★★★★ | 5 | 0 |
| Living Community Of St Joseph | 3.7 mi | ★★★★★ | 0 | 0 |
| Belleview Care Center | 4.5 mi | ★★★★★ | 2 | 0 |
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