Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 St Joseph Chateau during CMS and state inspections, most recent first.
A resident with complex psychiatric and medical needs was not allowed to return to the facility after a hospital stay, despite no documented evidence that the facility could not meet their needs. The facility initiated transfer to another SNF without providing a 30-day notice, discharge instructions, or information about appeal rights, and did not document a valid reason for the non-readmission. The guardian was not in agreement with the permanent transfer and reported feeling pressured due to the facility's refusal to readmit the resident.
A resident with complex psychiatric and medical needs was discharged without the facility providing the required 30-day written notice, bed hold policy, discharge summary, or reason for discharge to the court-appointed guardian. The facility also failed to provide a statement of appeal rights, Ombudsman contact information, and did not notify the Ombudsman of the discharge. Documentation and communication gaps were identified throughout the discharge process.
The facility failed to maintain a clean and safe environment, with observations of mold, damaged areas, and pest infestations. Staff and residents reported frequent sightings of mice, and the pest control company's recommendations were not implemented. The lack of adherence to maintenance and cleaning policies contributed to the ongoing issues.
The facility failed to ensure residents were cared for in a dignified manner, with two residents having their skin exposed in common areas and one resident avoiding the dining room due to excessive noise. Staff did not assist in covering exposed skin or addressing noise complaints, impacting the residents' quality of life.
The facility failed to maintain an accurate accounting of resident trust fund accounts by not performing monthly reconciliations. Bank statements from March 2023 through February 2024 showed no documentation of reconciliations, and attempted reconciliations did not match residents' current balances. The Business Office Manager confirmed the discrepancies, affecting funds for 56 residents.
The facility failed to maintain a clean and safe environment, with observations of sticky floors, chipped door frames, mold-like substances, and broken fixtures. Persistent urine odors and gnats were reported, particularly in the 200 hall. Staff and residents confirmed these issues, which had been ongoing for months.
The facility failed to provide written notices of transfer or discharge to residents or their responsible parties, including necessary details and appeal rights. This affected three residents, who were transferred to the emergency room without proper documentation. Interviews revealed a lack of a formal process to notify the Ombudsman of such transfers.
The facility failed to follow professional standards in medication administration and blood sugar monitoring. Staff did not check blood sugars prior to meals for two residents and failed to clarify a Vitamin D3 supplement order before administration. Interviews confirmed that orders must be followed precisely.
The facility failed to assess and maintain bed rails for two residents, leading to potential safety risks. One resident with severe cognitive impairment and hemiplegia, and another with moderate cognitive impairment and a seizure disorder, were observed with bed rails in the up position without proper assessments or physician's orders. Staff were unclear about responsibilities for entrapment assessments and bed measurements.
The facility failed to monitor monthly Medication Regimen Review (MRR) reports and did not ensure timely communication of pharmacist recommendations to physicians, affecting three residents. Delays in addressing recommendations for lab tests and medication changes were noted, with the Director of Nursing acknowledging the need for a faster process.
The facility failed to serve palatable, attractive, and safe food to three residents, with issues including cold temperatures and insufficient portions. Observations and staff interviews confirmed that food temperatures were below the required 135 degrees Fahrenheit, and complaints about cold food and small portions were common.
The facility failed to ensure that pureed foods were prepared in the correct consistency, affecting three residents with dysphagia. The pureed food was too thin and runny, posing a choking hazard. Dietary staff and the registered dietitian confirmed that the food consistency did not meet the required smooth, pudding-like texture.
The facility failed to maintain the kitchen in a sanitary manner, with dirt and debris observed in various areas, undated open food in freezers, and a lack of communication and responsibility for repairs and cleaning. Interviews revealed that staff were unaware of the needed repairs and cleaning, and the maintenance book did not show any requests for the kitchen.
The facility failed to maintain quarterly QAA committee meetings with the required members. The QAA committee met in April, June, October, January, and March, but the Medical Director only attended two of these meetings. The DON was unaware of the QAA and QAPI coordinator, and the Corporate Compliance Nurse indicated that the Administrator was responsible but was unaware of the Medical Director's attendance issues. The facility was in transition to a new Administrator.
The facility failed to follow infection control standards for medication administration when staff touched medications with ungloved hands for two residents. Additionally, the facility did not provide annual Tb testing for three residents, with staff showing a lack of clarity and responsibility regarding the administration and documentation of Tb tests.
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and mice droppings in various areas, including resident rooms and common areas. Staff and residents reported persistent issues, and structural problems were identified but not adequately addressed.
The facility failed to ensure dependent residents received necessary services for personal hygiene. Staff did not provide complete perineal and urinary catheter care to two residents, failing to clean all perineal folds and using the same area of wipes for different parts of the body. The DON confirmed the staff did not follow proper procedures.
The facility failed to supervise a resident with severe cognitive impairment and a history of choking during meals, as required by the care plan. Despite documented needs and staff acknowledgment, the resident was observed eating alone on multiple occasions, leading to a deficiency.
A resident experienced significant weight loss of over 10% in 3 months due to dissatisfaction with cold food and renal diet restrictions. Despite various nutritional interventions and recommendations from the RD, the weight loss continued. Staff and the resident reported issues with small portions and food quality, but these concerns were not effectively addressed by the facility.
Failure to Allow Resident Return and Inadequate Discharge Process
Penalty
Summary
A deficiency occurred when the facility failed to allow a resident to return after a hospital stay, without providing documented evidence that the resident's needs could not be met. The resident, who had a court-appointed guardian, had multiple diagnoses including major depressive disorder, diabetes, pulmonary disease, traumatic brain injury, Parkinson's disease, anxiety disorder, and paranoid schizophrenia. The care plan indicated the resident and guardian wished for long-term placement at the facility, and the resident had a history of attention-seeking behaviors and statements of self-harm, which were being managed through monitoring, therapy, and medication adjustments. Despite these interventions, the facility decided not to readmit the resident after a psychiatric hospital stay, citing concerns about ongoing suicidal ideation (SI) and the belief that the resident required a higher level of care. The facility initiated referrals to other skilled nursing facilities (SNFs) while the resident was still at the mental health hospital, and ultimately transferred the resident to another SNF without providing a documented reason that the resident's needs could not be met at the original facility. Communication records show that the guardian did not agree to a permanent transfer and expected the resident to return if no alternative placement was found. The facility did not provide a 30-day discharge notice, discharge instructions, or information about the right to appeal or contact the Ombudsman, as required by regulations. The guardian reported feeling pressured to accept the new placement due to the facility's refusal to readmit the resident. Interviews with facility staff, the guardian, and hospital staff confirmed that the facility had previously managed the resident's SI and behaviors with interventions such as one-on-one monitoring and medication adjustments. Staff acknowledged that there was no emergency requiring immediate transfer and that the facility could have continued to care for the resident. The decision to transfer was made without proper discharge planning, documentation, or regulatory notifications, and the accepting SNF was not screened to ensure it could meet the resident's needs. The lack of a documented reason for non-readmission and failure to follow required discharge procedures led to the deficiency.
Failure to Provide Required Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide the required written 30-day notice of discharge, bed hold policy, discharge summary, and the reason for discharge to the resident's court-appointed guardian. Additionally, the facility did not provide a statement of appeal rights, nor did it include the name, address, or telephone number of the Office of the State Long Term Care Ombudsman. The Ombudsman was also not notified of the resident's discharge. The facility was unable to provide its Discharge Policy upon request. The resident involved had multiple diagnoses, including major depressive disorder, diabetes, pulmonary disease, traumatic brain injury, Parkinson's disease, anxiety disorder, and paranoid schizophrenia. The care plan indicated the resident and guardian wished for long-term placement at the facility, and the resident had a history of psychiatric hospitalizations. On one occasion, the resident was transferred to an emergency room following a suicide hotline call, but there was no documentation of a bed hold notice, appeal rights, or Ombudsman contact information related to this transfer. The guardian did not receive discharge instructions, a recapitulation of the resident's stay, a final summary status, or a reconciliation of medications. Communication records show that the facility decided not to allow the resident to return after a psychiatric hospitalization, citing an inability to provide the necessary level of safety. The guardian was informed of this decision and agreed to a transfer to another skilled nursing facility only after being told the resident could not return. Interviews with facility staff and the guardian revealed conflicting accounts regarding the resident's wishes and the discharge process, but it was confirmed that the required written notifications and documentation were not provided to the guardian, and the Ombudsman was not notified.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations of unclean and damaged areas within the facility. Observations included a cracked ceiling with a dark substance at the nurses' station, mold-like substances in various locations such as the activity office and laundry room, and damaged sheetrock in the closet containing the ice machine. Additionally, the kitchen was found to have a sticky floor with food debris, and a mouse was observed stuck to a glue trap under the sink. The facility's pest control program was not effectively implemented, as evidenced by the presence of mice and other pests throughout the facility. Interviews with staff and residents revealed frequent sightings of mice in various areas, including resident rooms, the therapy office, and the activity office. The pest control company had made several recommendations to address structural concerns and sanitation issues, such as sealing holes and cleaning mouse droppings, but these recommendations were not acted upon. The facility's maintenance and cleaning policies were not adequately followed, contributing to the pest control issues. The Director of Maintenance acknowledged the lack of a maintenance person and the ongoing pest control problem. The Administrator was aware of the pest control issue and expected the facility to be clean and comfortable, with staff following the cleaning schedule and reporting cleanliness issues. However, the observations and interviews indicated that these expectations were not met, leading to the deficiency.
Failure to Maintain Resident Dignity and Dining Experience
Penalty
Summary
The facility failed to ensure residents were cared for in a dignified manner, as evidenced by two residents having their skin exposed in common areas. Resident #47, who has severe cognitive impairment and requires substantial assistance with dressing, was observed walking down the hall with exposed skin on the left chest. Despite passing multiple staff members, including CNAs, no one assisted in covering the resident's exposed skin. Similarly, Resident #32, who has a history of mental health diagnoses and requires supervision for dressing, was observed multiple times with their abdomen exposed while in common areas and in bed, without staff offering assistance to cover them up or pulling the privacy curtain in their room. Staff interviews confirmed that residents should not have exposed skin and that they should assist in covering them when noticed, but this was not done in these instances. Additionally, the facility failed to provide a dignified dining experience for Resident #14, who stopped eating in the dining room due to excessive noise from other residents playing music and using cell phones. The resident, who has minimal cognitive loss and requires supervision for ADLs, reported that the noise and occasional bad odors in the facility made it difficult to eat. Staff interviews corroborated the resident's complaints about the noise and odor, with the Housekeeping Supervisor and DON acknowledging persistent odors in certain hallways and the need for tile replacement. These deficiencies highlight the facility's failure to maintain a dignified environment for its residents, as required by their policy on promoting and maintaining resident dignity. The staff's inaction in addressing exposed skin and excessive noise in the dining room directly impacted the residents' quality of life and comfort within the facility.
Failure to Properly Reconcile Resident Trust Fund Accounts
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Specifically, the facility did not maintain an accurate accounting of all monies held in the resident trust fund account by failing to reconcile each month. Record reviews of the facility-maintained bank statements for account ending in #8793 from March 2023 through February 2024 showed no documentation of reconciliations. Additionally, the attempted reconciliations did not match the residents' current balances at the time of reconciliation. Email correspondence and an interview with the Business Office Manager confirmed that the reconciliations were not performed properly, affecting the funds managed for 56 residents out of a facility census of 62.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations of unclean and unsafe conditions. Specific issues included sticky floors, chipped and peeling door frames, dirty and debris-laden floors, and broken fixtures in resident rooms and common areas. Additionally, there were significant cleanliness issues in the dining rooms, hallways, and shower rooms, including mold-like substances, broken tiles, and malfunctioning equipment. These conditions were observed over several days and were corroborated by staff and resident interviews. Residents and staff reported persistent and strong urine odors, particularly in the 200 hall, which were attributed to residents urinating on the floors, mattresses, and in shared bathrooms. The facility's housekeeping and maintenance staff acknowledged these issues but failed to adequately address them. The Housekeeping Director admitted to not tracking or inspecting the completion of deep cleaning tasks, and the Maintenance Director was unaware of several maintenance issues, including loose handrails and broken fixtures. Interviews with residents and staff revealed that the urine odors and cleanliness issues had been ongoing for several months, with some staff resorting to wearing masks due to the strong odors. The facility's Director of Nursing (DON) and Administrator were aware of the problems but had not implemented effective solutions. The presence of gnats in resident rooms further indicated a lack of proper sanitation and pest control measures. Overall, the facility's failure to maintain a clean and safe environment compromised the residents' quality of life and well-being.
Failure to Provide Proper Transfer and Discharge Notices
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge to residents or their responsible parties, including the reasons for the transfer, in a language they understood. The notice should have included the effective date of discharge or transfer, the location to which the resident was transferred or discharged, a statement of the resident's appeal rights, and contact information for the Office of the State Long-Term Care Ombudsman. This deficiency affected one of 16 sampled residents, Resident #5, and the facility also failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, affecting three residents in total (Residents #5, #13, and #32). The facility census was 62 at the time of the survey. Resident #32, who had cognitive skills intact but required supervision for certain activities, was transferred to the emergency room for a psychiatric evaluation after exhibiting aggressive behavior. The facility did not have a copy of any discharge letter or documentation of the bed-hold letter sent with the resident. Similarly, Resident #5, who had severe cognitive impairment and multiple diagnoses including schizophrenia and hemiplegia, was transferred to the emergency room for evaluation after showing signs of a stroke. The record did not contain a copy of any discharge letter or bed-hold letter documentation. Resident #13, who had no cognitive impairment but had a history of psychotic disorder, anxiety, and depression, was transferred to the emergency room after exhibiting aggressive behavior and refusing redirection. The facility did not have a copy of the notice provided to a representative of the Office of the State Long-Term Care Ombudsman. Interviews with the Social Services Designee and the Director of Nursing revealed that there was no formal process in place to notify the Ombudsman of transfers and discharges, and the Director of Nursing believed that Social Services was handling these notifications as a group.
Failure to Follow Professional Standards in Medication Administration and Blood Sugar Monitoring
Penalty
Summary
The facility failed to ensure staff followed professional standards of quality in the administration of medications and monitoring of blood sugars for residents. Specifically, staff did not check blood sugars prior to meals for two residents, Resident #32 and Resident #53, and failed to obtain blood sugars on the day ordered by the physician for Resident #53. Additionally, there was no physician's order to check blood sugars for Resident #32, and a Vitamin D3 supplement order for Resident #41 was not clarified before administration. These deficiencies were observed during a survey where staff did not adhere to the facility's medication administration policy, which mandates that medications be administered as ordered by the physician and in accordance with professional standards of practice. For Resident #53, the physician's order required weekly blood sugar checks on Saturdays, but the resident's blood sugar was checked on a different day, and insulin was administered post-breakfast. For Resident #32, there was no physician's order for blood sugar checks, yet the resident's blood sugar was checked after breakfast, and insulin was administered. The resident refused the fast-acting insulin. For Resident #41, a Certified Medication Technician administered Vitamin D3 without clarifying the dosage, despite recognizing the discrepancy in the order. Interviews with staff, including an LPN and the Director of Nursing, confirmed that blood sugars should be obtained before meals and that orders must be followed precisely.
Failure to Assess and Maintain Bed Rails
Penalty
Summary
The facility failed to assess residents for risk of entrapment from bed rails prior to installation and did not ensure the bed's dimensions were appropriate for the resident's size and weight. Additionally, the facility did not perform scheduled maintenance of the bed rails for two of the 16 sampled residents. Resident #5, who had severe cognitive impairment, hemiplegia, and a history of falls, was observed with a bed rail in the up position without a physician's order or an entrapment assessment. The resident's care plan and MDS did not indicate the use of bed rails, and staff were unsure of the reasons for the bed rail's presence or who was responsible for the entrapment assessments and measurements. The maintenance supervisor also confirmed the lack of documentation for entrapment assessments and measurements since their tenure began three months prior. Resident #19, who had moderate cognitive impairment, heart failure, dementia, and a seizure disorder, was also observed with bed rails in the up position on both sides of the bed without a physician's order or an entrapment assessment. The resident's care plan indicated the use of bed rails for bed mobility, but there was no documentation of an entrapment assessment. Interviews with staff, including the physical therapy assistant, registered nurse, and maintenance supervisor, revealed confusion and lack of clarity regarding the responsibility for conducting entrapment assessments and measuring bed dimensions. The Director of Nursing was also unsure of the policy and where maintenance documented the measurements. The facility's undated Side Rails Policy required an assessment for risk of entrapment, obtaining a physician's order, ensuring correct installation and maintenance, and inspecting the mattress and bed rails for gaps and areas of possible entrapment. However, the facility did not adhere to these procedures, resulting in the deficiency. The lack of proper assessments, documentation, and maintenance of bed rails posed a potential risk to the residents' safety.
Failure to Address Pharmacist Recommendations in a Timely Manner
Penalty
Summary
The facility failed to monitor the monthly Medication Regimen Review (MRR) reports for November 2023 and January 2024, completed by the pharmacist, and did not ensure that recommendations were addressed with Resident #5's physician by midnight of the next calendar day. This affected three residents. For Resident #5, the pharmacist recommended a monthly complete blood count (CBC) due to the resident's Clozapine medication, but the facility did not address this recommendation with the physician until March 2024. Resident #5 had moderate cognitive impairment and required substantial assistance with daily activities, and was on multiple medications including antipsychotics and antidepressants. Similarly, for Resident #19, the pharmacist noted the absence of a Valproic Acid level lab result, which was due in December 2023. The facility did not address this with the physician until March 2024. Resident #19 also had moderate cognitive impairment and required substantial assistance with daily activities, and was on multiple medications including antipsychotics and diuretics. For Resident #39, the pharmacist recommended discontinuing Hydroxyzine for anxiety, but the facility did not address this with the physician until March 2024. Resident #39 had no cognitive impairment but required moderate to substantial assistance with daily activities and was on multiple medications including antidepressants and opioids. During an interview, the Director of Nursing (DON) acknowledged that the process for addressing pharmacist recommendations was slow, taking 7 to 10 days for the physician to review and act on them. The DON mentioned that the pharmacist emails the recommendations, which are then placed in a folder for the physician to review during their weekly visits on Fridays. This delay in addressing the recommendations led to the deficiencies noted in the report. The DON has been working on improving the time frame since May 2023 but acknowledged that the process still needs to be faster.
Failure to Serve Palatable and Safe Food
Penalty
Summary
The facility failed to serve food to the residents that was palatable, attractive, and served at a safe and appetizing temperature. This deficiency affected three residents. Resident #34, who had no cognitive impairment and was independent with activities of daily living (ADLs), was served a bowl of dumplings that was only a quarter full and cold. Resident #47, who had severe cognitive impairment and required extensive assistance, was not offered a meal tray and ended up eating cold food from an uncovered plate in their room. Resident #33, who had intact cognitive skills but required extensive assistance with ADLs, reported that the food received in their room was usually cold. Observations of meal preparation and test trays revealed that the temperatures of the food were below the required 135 degrees Fahrenheit. The pureed green beans were 97 degrees Fahrenheit, the regular hamburger was 98 degrees Fahrenheit, and the pureed chicken was 105 degrees Fahrenheit. Additionally, the pureed green beans were very thin and ran off the spoon like water. Interviews with the dietary staff confirmed that the residents should receive full servings of food and that hot food should be served at temperatures above 135 degrees Fahrenheit. Interviews with various staff members, including a Licensed Practical Nurse (LPN), a Certified Medication Technician (CMT), and a Certified Nurse Aide (CNA), indicated that complaints about cold food and small portion sizes were common among the residents. The Registered Dietitian also confirmed that residents should receive full servings and that pureed food should not be runny. Despite these guidelines, the facility failed to meet the standards for food service, resulting in dissatisfaction and potential health risks for the residents.
Failure to Ensure Proper Consistency of Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared in a consistency designed to meet the needs of individual residents. Specifically, the pureed food provided to three residents (Residents #5, #19, and #47) was observed to be too thin and runny, posing a choking hazard. The dietary manager and Cook A were responsible for preparing the pureed meals, but the food consistency did not meet the required smooth, pudding-like texture. This inconsistency was confirmed through observations and interviews with the dietary staff and the registered dietitian, who all acknowledged that the pureed food should not be runny like liquid. Resident #5, who had a history of dysphagia and was on a pureed diet, was served food that was not properly prepared, increasing the risk of choking. Similarly, Resident #19, who also had swallowing difficulties and required a pureed diet, received improperly prepared food. Resident #47, with severe cognitive impairment and a need for a pureed diet due to dysphagia, was also affected. The facility's failure to provide the requested policy on pureed food preparation further highlights the deficiency in ensuring the safety and dietary needs of these residents.
Sanitation and Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored and the kitchen was maintained in a sanitary manner. Observations revealed that the floor under the three-compartment sink, the ceiling above it, and the top of the dishwasher were covered with dirt and debris. Additionally, baseboards and tiles were missing under the dishwasher, and vents in the ceiling above the coolers were dirty. The wheels of the meal carts were also covered with dirt and debris. Further observations showed that the vent and window by the handwashing sink were dirty, the plate warmer had food spatters, and the kitchen ceiling had peeling paint. The dry storage area had bugs in the light and debris on the floor. The chest freezer contained undated open bags of food and was dirty inside, while the upright freezer had dirt and debris on the sides and bottom, and its drawers were cracked and chipped with dirt inside them. Interviews with the Dietary Manager, Maintenance Director, Registered Dietitian, and Administrator revealed a lack of communication and responsibility for maintaining the kitchen's cleanliness and repair. The Dietary Manager acknowledged that the kitchen should be clean and in good repair, with food labeled and dated, and no open containers in the refrigerator or freezer. The Maintenance Director, who had only been at the facility for three weeks, was unaware of the needed repairs and cleaning in the kitchen. The Registered Dietitian and Administrator both expected the kitchen to be clean, sanitary, and in good repair, with proper food storage. However, the maintenance book at the nurse's desk did not show any repair or cleaning requests for the kitchen, indicating a breakdown in the reporting and addressing of maintenance issues.
Failure to Maintain Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to maintain quarterly Quality Assessment and Assurance (QAA) committee meetings with the required members. The facility's policy mandates that the QAA committee be interdisciplinary, including the Director of Nursing (DON), the Medical Director or designee, the infection preventionist, and at least three other staff members, and that it meets at least quarterly. Review of sign-in sheets from April 2023 to March 2024 revealed that the committee met in April 2023, June 2023, October 2023, January 2024, and March 2024. However, the Medical Director only attended the meetings in June 2023 and March 2024, and there was no sign-in sheet for the quarter between June 2023 and October 2023. During interviews, the DON was unaware of who was responsible for QAA and QAPI coordination, while the Corporate Compliance Nurse indicated that the Administrator was in charge but was unaware of the Medical Director's attendance issues. The facility was in a state of flux due to the transition to a new Administrator.
Infection Control and Tb Testing Deficiencies
Penalty
Summary
The facility failed to follow infection control standards and guidelines for medication administration when staff touched medications with ungloved hands for two residents. One resident, who had diagnoses including OCD, stroke, and paranoid schizophrenia, was observed receiving Vitamin D and Cranberry tablets that were handled by a Certified Medication Technician (CMT) with bare hands. Another resident, with diagnoses including stroke, aphasia, and Parkinson's disease, was given Depakote Sprinkles that were placed directly on the medication cart surface and handled without gloves by a CMT. Additionally, the facility failed to provide annual tuberculosis (Tb) testing for three residents. These residents had various diagnoses such as dementia, stroke, and coronary artery disease, and their medical records showed that their last Tb tests were administered over a year ago. The Infection Preventionist (IP) and the Assistant Director of Nursing were interviewed, revealing a lack of clarity and responsibility regarding the administration and documentation of Tb tests. The Director of Nursing (DON) confirmed that staff should not handle medications with bare hands or place pills directly on the medication cart without a barrier. The DON also indicated uncertainty about the timing and responsibility for annual Tb testing, highlighting a gap in the facility's infection prevention and control program.
Pest Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and mice droppings in various areas, including resident rooms, the dining room, and common areas. Observations on multiple dates revealed gnats in residents' rooms, the dining room, the hall, the beauty shop, and the front office area. Interviews with staff confirmed the persistent presence of gnats, with one Certified Nurse Aide noting that gnats were always in the building. The Administrator acknowledged delays in addressing the issue and mentioned that pest control had treated a drain where gnats were nesting. However, the problem persisted despite these efforts. Additionally, mice droppings were observed in two residents' rooms, on bedside tables, dressers, floors, and refrigerators. A mouse was also seen running down the hall and through a hole under the exit doors. Interviews with residents and staff indicated that complaints about mice had been made but not adequately addressed. The maintenance supervisor and pest control company manager both noted structural issues, such as gaps in doors and holes in walls, that facilitated the pest problem. Despite recommendations to fix these issues, the facility had not taken the necessary actions, leading to ongoing pest control deficiencies.
Failure to Provide Complete Perineal and Catheter Care
Penalty
Summary
The facility failed to ensure that dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. Specifically, staff did not provide complete perineal and urinary catheter care to two residents. For Resident #20, who had long and short-term memory problems, hemiplegia, and was always incontinent of bowel and bladder, the CNA did not properly clean all perineal folds and used the same area of the wipe for different parts of the body. Additionally, the mattress was not cleaned after the resident urinated on it. The care plan indicated that the resident required extensive assistance for toileting due to dementia and hemiplegia. For Resident #33, who had cognitive skills intact but was dependent on staff for toilet use and transfers, the CNA did not anchor the catheter tubing and failed to clean all perineal folds properly. The resident had a urinary catheter and was always incontinent of bowel. The CNA used the same area of a wipe for different parts of the body and did not separate and clean all areas of the skin where urine had touched. The Director of Nursing confirmed that the staff did not follow proper procedures for perineal and catheter care, including not using the same area of the wipe and not anchoring the catheter tubing.
Failure to Supervise Choking Risk Resident During Meals
Penalty
Summary
The facility failed to provide supervision while eating for a resident who is a choking risk, as outlined in the resident's care plan. The resident, who has severe cognitive impairment, dysphagia, and a history of choking episodes, was observed eating alone in their room on multiple occasions without staff supervision. Despite the care plan and staff acknowledgment that the resident requires supervision during meals, the resident was left unsupervised while eating on at least three separate occasions. Interviews with staff revealed inconsistencies in their understanding and execution of the supervision requirement, with some staff unaware of the need for supervision and others failing to follow through on the care plan directives. The resident's care plan, dated 10/23/23, indicated the need for supervision due to right-sided hemiplegia, cognitive deficits, and a history of choking episodes. The resident's Quarterly Minimum Data Set (MDS) dated 2/9/24, confirmed severe cognitive impairment and the need for substantial assistance with ADLs, including eating. Despite these documented needs, observations on 3/26/24, 3/27/24, and 3/28/24 showed the resident eating alone in their room. Interviews with the RN, CNA, and DON confirmed that the resident should not eat without supervision, yet this protocol was not consistently followed, leading to the deficiency noted in the report.
Failure to Prevent Significant Weight Loss in Dialysis Resident
Penalty
Summary
The facility failed to prevent significant weight loss of more than 10% of a resident's body weight in a 3-month period. The resident, who was at nutritional risk and received dialysis, experienced a total weight loss of 23.1 lbs or 15.38% over 90 days. Despite being on a therapeutic diet and receiving various nutritional interventions, the resident continued to lose weight. The resident expressed dissatisfaction with the food, stating it was always cold and that they did not like the renal diet restrictions. Multiple complaints about small portions and the inability to get desired food were also noted by staff and the resident. The facility's policy on weight monitoring required that significant weight changes be reported to the physician, and appropriate interventions be implemented. However, the primary care physician and the Advanced Practice Registered Nurse (APRN) were not aware of the resident's significant weight loss. The Registered Dietician (RD) had made several recommendations to liberalize the resident's diet and provide supplements, but these were not effectively communicated or implemented. The resident's weight continued to decline despite these efforts. Interviews with staff revealed that multiple residents had complained about small portion sizes and cold food, which contributed to weight loss. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) acknowledged the resident's significant weight loss and the issues with the renal diet but did not take effective action to address these concerns. The Administrator was also unaware of any complaints about portion sizes or food quality, indicating a lack of communication and follow-up on these issues within the facility.
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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) |
|---|---|---|---|---|
| Advanced Care Of St Joseph | 1.3 mi | ★★★★★ | 2 | 0 |
| St Joseph Manor Health & Rehabilitation | 2.3 mi | ★★★★★ | 2 | 0 |
| Carriage Square Rehab And Healthcare Center | 3.1 mi | ★★★★★ | 5 | 0 |
| Living Community Of St Joseph | 4.1 mi | ★★★★★ | 0 | 0 |
| Belleview Care Center | 4.3 mi | ★★★★★ | 2 | 0 |
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