Inspection Reports for
Advanced Care of St Joseph

The complaint investigation found that two residents (Residents #1 and #2) were moved multiple times without written notification or consent, causing emotional distress. The Social Services Director confirmed that notifications were often last minute and no written notices were provided.

The facility failed to protect two residents' rights to choice by not providing written notification of room changes and moving residents without their consent, causing distress. The facility had no policy or process for room changes and notifications were often given at the last minute or not at all.

The complaint investigation was triggered by resident reports of catheter bags not being emptied frequently enough, resulting in discomfort and distress. The resident called the reception desk multiple times and used the call light repeatedly without timely staff response. The complaint was substantiated with observations and interviews confirming inadequate catheter care and delayed response times.

The facility failed to ensure proper catheter care, including cleaning catheter tubing away from the insertion site and timely emptying of the urinary collection bag, resulting in potential risk for urinary tract infections. Staffing shortages contributed to delays in responding to resident call lights for catheter care.

The complaint investigation was triggered by allegations of failure to maintain resident dignity, retaliation or intimidation of a resident, failure to provide timely incontinence care, and failure to address resident grievances properly. Some grievances involved concerns about food quality, staff behavior, and showering frequency.

The facility failed to maintain resident dignity by not removing unwanted facial hair and providing timely incontinence care, failed to act promptly on resident council grievances, failed to ensure residents knew how to file grievances and follow up on them, failed to provide showers timely for some residents, and failed to maintain proper food safety and hygiene standards in the kitchen.

The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate response to resident grievances, incomplete care planning, delayed showers, medication administration errors, improper catheter care, inadequate pain management, food quality concerns, and infection control lapses.

The complaint investigation found that the facility did not follow policies requiring neurological assessments after falls, failed to notify nursing staff promptly, and did not document the fall on 12/4/24. The resident suffered increased confusion and a fractured collar bone as a result.

The facility failed to initiate neurological assessments after an unwitnessed fall of Resident #1, who was found on the floor with bruises and increased confusion. Certified Nursing Assistants assisted the resident off the floor without notifying nursing staff immediately, and the fall was not documented on the day it occurred. The resident later was found to have a fractured collar bone and was sent to the hospital.

The facility failed to maintain accurate accounting of residents' personal funds, with discrepancies in petty cash balances and missing records for six months. Additionally, licensed nursing staff failed to administer medications timely for three residents and left blanks in medication and treatment administration records, indicating non-compliance with professional standards of care.

The facility was found deficient in multiple areas including failure to provide timely written transfer notices and bed hold policy notifications, inaccurate Minimum Data Set coding, incomplete care planning for skin conditions, inadequate respiratory care and equipment sanitation, failure to post daily nurse staffing information, lack of behavior monitoring for psychotropic medication use, improper medication storage, ineffective infection control practices including isolation and barrier precautions, failure to maintain a pest control program, and lapses in hand hygiene during meal service.

The complaint investigation revealed that Resident #1 repeatedly brought illegal drugs into the facility, resulting in multiple overdoses requiring Narcan administration. Resident #2, the roommate, was severely cognitively impaired and dependent on staff, and was exposed to unsafe conditions. The facility failed to implement effective interventions or supervision to prevent drug use or protect residents. The resident's responsible parties and guardians were not consistently notified. The facility acknowledged the issues but lacked adequate measures to address them, leading to a discharge notice for Resident #1 due to safety concerns.

The facility failed to operationalize its Illegal Drug Use policy to ensure a safe environment, as illegal drugs and paraphernalia were repeatedly found in a shared room occupied by two residents. Resident #1 experienced multiple overdoses requiring Narcan administration, and the facility lacked adequate supervision and interventions to prevent drug use and ensure resident safety.

The complaint involved an allegation of sexual abuse by Resident #4 against Resident #3. The investigation was inconclusive due to incomplete interviews and documentation. Resident #4 denied the allegation and was moved to a new room with restrictions. Law enforcement was involved and interviewed residents and staff.

The facility failed to thoroughly investigate the sexual abuse allegation, including incomplete staff and resident interviews and inadequate documentation. Additionally, licensed nursing staff failed to ensure physician orders were followed for two residents, with missing medication and treatment documentation and improper medication handling.

The complaint involved an allegation of sexual abuse by Resident #4 against Resident #3. The investigation was inconclusive due to incomplete interviews and documentation. The allegation was not substantiated.

The facility failed to thoroughly investigate the sexual abuse allegation, missing interviews with all staff and residents, and incomplete documentation. Medication administration was deficient with missing documentation and improper medication storage. Food service safety was compromised due to unsanitary kitchen conditions, improper food storage, lack of temperature monitoring, inadequate sanitation practices, and poor hand hygiene among staff.

The complaint investigation found that the facility staff failed to prevent the elopement of Resident #1 on 12/5/23. The resident left the facility unsupervised, became intoxicated, and was hospitalized. The resident's Durable Power of Attorney was notified, and law enforcement was involved. The facility did not implement new interventions post-elopement and did not report the incident to the Department of Health and Senior Services. The resident threatened to leave again and signed a form regarding leaving against medical advice.

The facility failed to adequately supervise and prevent the elopement of Resident #1, who left the facility unsupervised, became intoxicated, and was hospitalized. The resident's care plan did not include elopement or wandering risk, and no new interventions were implemented after the incident. Staff and administration responses to the elopement were documented, including notification of family and law enforcement involvement.

The facility failed to provide personal funds and a final accounting within thirty days upon discharge for six sampled residents and did not have a policy regarding Resident Trust Funds. Additionally, the facility failed to ensure timely payment of city water and sewer bills, resulting in a large outstanding balance, and lacked a policy addressing timely bill payments.

The facility failed to provide personal funds and a final accounting within thirty days upon discharge for seven residents, and failed to prepare, store, and serve food in accordance with professional standards, including improper labeling and storage of food items.