Inspection Reports for
Living Community of St Joseph
1202 HEARTLAND RD, SAINT JOSEPH, MO, 64506-3200
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
19.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
251% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
59% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 2
Date: Apr 23, 2025
Visit Reason
The inspection was conducted due to a complaint regarding a resident fall incident and the facility's failure to provide adequate supervision and assistance during gait belt transfers.
Complaint Details
Complaint investigation related to a resident fall incident where the resident was transferred without a gait belt, resulting in injury. The complaint was substantiated based on interviews, record reviews, and observations.
Findings
The facility failed to ensure one resident received adequate assistance and supervision during transfer, resulting in a fall and a fractured hip requiring surgery. The care plan did not address the resident's mobility assistance needs, and staff did not follow facility policy on gait belt use.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) The facility failed to ensure the resident environment was free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. One resident fell after being transferred without a gait belt, resulting in a fractured hip requiring surgery.
A4075 19 CSR 30-85.042(66) Nursing Care per Resident Condition Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the F689 deficiency.
Report Facts
Facility census: 77
Deficiency tags cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in the fall incident report and transfer without gait belt |
| CNA A | Certified Nurses Aide | Witnessed the fall and involved in transfer without gait belt |
| LPN B | Licensed Practical Nurse | Monitored vital signs and neurological assessments after fall |
| Registered Nurse (RN) A | Registered Nurse | Interviewed regarding gait belt use policy |
| Physical Therapist (PT) A | Physical Therapist | Interviewed regarding facility policy on gait belt use |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding expectations for care plans and staff education |
Inspection Report
Routine
Census: 80
Deficiencies: 6
Date: Jan 2, 2025
Visit Reason
Routine inspection of Living Community of St Joseph nursing home to assess compliance with regulations including medication self-administration, abuse prevention, resident assessments, fall prevention, psychotropic medication use, and medical record accuracy.
Findings
The facility failed to ensure proper self-administration of medications for two residents, did not thoroughly investigate verbal abuse allegations, had inaccurate resident assessments, failed to prevent falls and wandering risks, lacked end dates on PRN psychotropic medication orders, and maintained inaccurate medical records regarding a resident's mental health diagnosis.
Deficiencies (6)
F 0554: The facility failed to ensure two residents were properly permitted or restricted in self-administration of medications, resulting in medications being left at bedside without proper assessment or orders.
F 0610: The facility failed to conduct a thorough investigation of verbal abuse allegations involving two residents, lacking documentation of interviews and assessments.
F 0641: The facility failed to ensure one resident had an accurate Minimum Data Set assessment, omitting documented wandering behavior despite care plans indicating such.
F 0689: The facility failed to provide adequate supervision and interventions to prevent falls and wandering for two residents, resulting in multiple falls with injuries and wandering into other residents' rooms.
F 0758: The facility failed to include end dates on PRN psychotropic medication orders for two residents, risking continued use without ongoing assessment.
F 0842: The facility failed to maintain accurate medical records for one resident, documenting an inaccurate bipolar disorder diagnosis and lacking the current PASRR Level 1 form.
Report Facts
Facility census: 80
BIMS score: 12
BIMS score: 15
BIMS score: 6
BIMS score: 13
BIMS score: 4
BIMS score: 15
BIMS score: 15
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CM1 | Clinical Manager | Named in medication self-administration and medication removal findings |
| DON | Director of Nursing | Named in multiple findings including medication self-administration, abuse investigation, fall prevention, and psychotropic medication management |
| RN1 | Registered Nurse | Named in fall incident findings and supervision |
| LPN4 | Licensed Practical Nurse | Named in medication self-administration findings |
| CNA1 | Certified Nursing Assistant | Named in wandering and fall supervision findings |
| Administrator | Facility Administrator | Named in medical record accuracy and PASRR findings |
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 6
Date: Jan 2, 2025
Visit Reason
A recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services to assess compliance with 42 CFR 483 subpart B.
Findings
The facility was found not to be in substantial compliance with multiple deficiencies related to resident self-administration of medications, abuse investigations, accuracy of assessments, free of accident hazards, psychotropic drug use, and resident records. Several residents were found at risk due to medication management, abuse allegations, wandering behaviors, and fall risks.
Deficiencies (6)
F554 Resident Self-Admin Meds-Clinically Appropriate: The facility failed to ensure medications were not left at the bedside of a resident not assessed to self-administer safely and failed to ensure another resident desiring to self-administer was permitted to do so safely.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to conduct a thorough investigation of an allegation of verbal abuse by a staff member for two residents, creating potential for abuse of other residents.
F641 Accuracy of Assessments: The facility failed to ensure one of 25 sampled residents had an accurate Minimum Data Set (MDS) assessment.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure two of 25 sampled residents were provided with sufficient supervision and assistive devices to prevent accidents, resulting in falls and injuries.
F758 Free from Unnec Psychotropic Meds/PRN Use: The facility failed to have an end date for PRN psychotropic medication orders for two residents, risking unnecessary medication use.
F842 Resident Records - Identifiable Information: The facility failed to ensure medical records were accurate and complete for one of 25 sampled residents, including failure to document serious mental illness and PASRR Level 1 screening.
Report Facts
Survey Census: 80
Sample Size: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Johnson | SNF Administrator | Signed the initial comments page of the report |
| Director of Nursing | Named in findings related to medication administration and abuse investigation | |
| Clinical Manager | Named in findings related to medication administration and abuse investigation | |
| Licensed Practical Nurse (LPN) 4 | Interviewed regarding medication administration and abuse allegations | |
| Certified Medication Technician (CMT) 1 | Interviewed regarding medication administration |
Inspection Report
Plan of Correction
Census: 80
Capacity: 95
Deficiencies: 1
Date: Jan 2, 2025
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found to be noncompliant with Life Safety Code requirements due to failure to ensure weekly testing of the dry sprinkler system's gauges. No documentation was provided for weekly inspections of the sprinkler gauges.
Deficiencies (1)
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure the dry sprinkler system's gauges were tested weekly as required by NFPA 25. Records showed no documented evidence of weekly inspections and the Maintenance Director could not provide documentation during the survey.
Report Facts
Number of occupied beds: 80
Total licensed beds: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Katie Johnson | SNF Administrator | Signed the plan of correction form |
| Maintenance Director | Interviewed regarding sprinkler gauge inspections |
Inspection Report
Annual Inspection
Census: 95
Capacity: 95
Deficiencies: 23
Date: Mar 6, 2023
Visit Reason
The inspection was the annual survey of the Living Community of St Joseph to assess compliance with federal and state regulations for skilled nursing facilities.
Findings
The facility was found to have multiple deficiencies across various regulatory areas including personal funds management, abuse prevention, resident assessments, care planning, nursing services, medication administration, and food safety. A plan of correction was submitted to address these deficiencies.
Deficiencies (23)
F567: The facility failed to ensure credit balances on resident accounts are refunded within 30 days post discharge.
F607: The facility failed to ensure all new hires are checked against the CNA registry.
F636: The facility failed to ensure completion of comprehensive MDS assessments according to required timeframes.
F640: The facility failed to ensure completion and transmission of MDS assessments according to required timeframes.
F656: The facility failed to develop and implement a comprehensive person-centered care plan.
F657: The facility failed to review and update the comprehensive care plan to address residents with significant changes in health care status.
F658: The facility failed to ensure care and treatment is provided in accordance with professional standards.
F677: The facility failed to provide necessary care and services to maintain good personal hygiene.
F693: The facility failed to ensure nursing staff dated and timed enteral feeding bags at the time of administration.
F695: The facility failed to properly store oxygen therapy care specifically following oxygen administration orders, concentrator filters and tubing.
F759: The facility failed to ensure medication administration error rate of less than 5%.
F804: The facility failed to ensure food served was at an appropriate temperature.
F809: The facility failed to ensure meals are provided according to scheduled meal times.
A4017: The facility failed to conduct criminal background checks within required timeframes.
A4034: The facility failed to ensure all staff wore name badges.
A4055: The facility failed to maintain a safe and effective medication system.
A4075: The facility failed to provide appropriate nursing care per resident condition.
A4108: The facility failed to maintain clinical records with sufficient information.
A5003: The facility failed to prepare and serve foods that conserve nutritive value, flavor and appearance.
A5005: The facility failed to ensure hot food was served hot and cold food was served cold.
A5010: The facility failed to establish a time schedule for meals within regulatory requirements.
A7015: The facility failed to protect residents during food service.
A9010: The facility failed to meet discharge requirements within 5 days.
Report Facts
Facility census: 95
Total licensed capacity: 95
Medication administration error rate: 32
Medication administration error rate: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sally Johnson | SNF Administrator | Signed plan of correction and involved in facility administration |
Inspection Report
Life Safety
Census: 95
Capacity: 96
Deficiencies: 11
Date: Mar 6, 2023
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and emergency preparedness requirements at the Living Community of St Joseph.
Findings
The facility failed to maintain an updated emergency preparedness plan, did not ensure proper locking arrangements on egress doors, lacked adequate fire sprinkler coverage, and had deficiencies in electrical system maintenance and fire watch policies. Several life safety code violations were cited, including issues with door locks, sprinkler systems, smoking regulations, and electrical equipment testing.
Deficiencies (11)
E004 Emergency Preparedness Plan. The facility failed to review and update the emergency preparedness plan annually, with the last review dated 2017.
E015 Emergency Preparedness Subsistence Needs. The facility lacked policies addressing alternate energy sources, emergency lighting, fire detection, and waste disposal.
K222 Egress Doors. The facility used magnetic locks on exit doors that did not comply with delayed egress locking requirements, risking resident safety.
K351 Sprinkler System Installation. The facility failed to provide fire sprinkler coverage in an executive director's closet.
K353 Sprinkler System Maintenance. The facility failed to maintain sprinkler heads free from dirt, dust, debris, corrosion, and paint.
K354 Sprinkler System Out of Service. The sprinkler system was out of service for more than 10 hours without an approved fire watch.
K741 Smoking Regulations. The facility failed to ensure proper disposal of cigarettes, resulting in littered cigarette butts on the premises.
K901 Fundamentals - Building System Categories. The facility did not assign risk assessment categories or document assessments for building systems.
K914 Electrical Systems Maintenance. The facility failed to properly document annual testing of non-hospital grade electrical receptacles in patient sleeping areas.
K918 Electrical Systems Essential Electric System. The facility failed to maintain and test the generator and transfer switches as required.
K920 Electrical Equipment Power Strips. The facility failed to ensure power strips were used safely and properly monitored.
Report Facts
Facility Capacity: 96
Census: 95
Deficiencies cited: 11
Inspection Report
Routine
Census: 95
Deficiencies: 15
Date: Mar 6, 2023
Visit Reason
Routine inspection of Living Community of St Joseph nursing home to assess compliance with regulatory requirements including resident rights, staff qualifications, resident assessments, care planning, medication administration, food service, and facility cleanliness.
Findings
The facility was found deficient in multiple areas including failure to reimburse discharged residents timely, incomplete staff registry checks, late and incomplete Minimum Data Set (MDS) assessments and care plans, medication administration errors, improper food handling and storage, delayed meal service, and inadequate respiratory care including unclean oxygen concentrator filters.
Deficiencies (15)
F 0567: Facility failed to hold residents' monies separate and reimburse discharged residents timely, affecting six residents. Refund requests were delayed and lacked proper approval.
F 0607: Facility failed to check the Certified Nurses' Assistant Registry for all staff, including non-nursing staff, to ensure no federal abuse indicators were present, affecting four staff members.
F 0636: Facility failed to complete and submit federally mandated Minimum Data Set (MDS) assessments timely for two residents, resulting in late or missing assessments.
F 0638: Facility failed to complete, submit, and have accepted quarterly MDS assessments for six residents, resulting in missing quarterly assessments.
F 0640: Facility failed to transmit federally mandated MDS assessment data to the state within required timeframes for six residents, resulting in missing quarterly assessments.
F 0656: Facility failed to develop and implement comprehensive care plans consistent with residents' assessments for four residents, lacking measurable objectives and interventions for identified needs.
F 0657: Facility failed to review and revise comprehensive care plans after significant changes in condition for one resident, resulting in outdated care plans.
F 0658: Facility failed to provide care and treatment in accordance with professional standards for three residents, including unlabeled and undated dermal patches, improper nasal spray administration, and incorrect inhaler use.
F 0677: Facility failed to provide necessary assistance with activities of daily living for two residents, resulting in poor personal hygiene and unshaved facial hair.
F 0693: Facility failed to date and time enteral feeding bags for one resident, risking administration of spoiled formula.
F 0695: Facility failed to provide safe and appropriate respiratory care for four residents, including failure to clean oxygen concentrator filters and failure to follow oxygen therapy orders.
F 0761: Facility failed to store drugs and biologicals in locked compartments and failed to discard expired medications, with medications found in residents' rooms without orders and expired medications present.
F 0804: Facility failed to ensure food was palatable, attractive, and served at safe and appetizing temperatures, with multiple residents reporting cold food and observations of food served below safe temperatures.
F 0809: Facility failed to serve meals according to scheduled meal times, with meal service delays up to over an hour past posted times, affecting multiple residents.
F 0812: Facility failed to store, prepare, and serve food in accordance with professional standards, including undated and uncovered food items, food stored on the floor, dirty kitchen and food prep areas, and inadequate handwashing by food service staff.
Report Facts
Medication errors: 6
Residents affected by census: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in medication administration and patch application findings |
| CNA F | Certified Nurses' Aide | Observed moving patch on resident causing grimace |
| Culinary Services Director | Interviewed regarding food temperature and kitchen sanitation | |
| Culinary Assistant Supervisor | Interviewed regarding food service and sanitation | |
| LPN B | Licensed Practical Nurse | Interviewed regarding feeding tube care and oxygen therapy |
| Administrator | Interviewed regarding meal service complaints and care plan expectations |
Inspection Report
Plan of Correction
Census: 23
Deficiencies: 7
Date: Mar 6, 2023
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Living Community of St Joseph, related to a state survey conducted on 03/06/2023.
Findings
The facility was found deficient in multiple areas including failure to ensure staff wore identification badges, failure to follow infection control procedures such as wearing gloves and hand hygiene during medication administration, failure to wash hands and arms as necessary, improper food storage and labeling, failure to maintain proper food temperatures, and inadequate cleaning and sanitizing of food-contact surfaces.
Deficiencies (7)
19 CSR 30-86.047(16) Identification Badge Requirements: The facility failed to ensure all staff wore identification badges while on duty or delivering services. The facility census was 23.
19 CSR 30-86.047(34)(A) Disease/Infection Control, Report Category I: The facility failed to follow infection control procedures by touching resident medications without gloves and not performing hand hygiene when passing medications. The census was 23.
19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails: The facility failed to ensure employees washed hands and arms as often as necessary during work. The census was 23.
19 CSR 30-87.030(11) Food-Safe, Obtain From Appropriate Sources: The facility failed to store food in identifying containers and allowed undated and uncovered food items. The census was 23.
19 CSR 30-87.030(15) Food-Stored Above the Floor, Protected: The facility failed to ensure staff did not store food on the floor. The census was 23.
19 CSR 30-87.030(24) Hot Food-140 Degrees or Above/Transport: The facility failed to hold food temperatures at 140 degrees Fahrenheit or above during transport and service. The census was 23.
19 CSR 30-87.030(65) Nonfood Contact Surfaces, Cleaned as Needed: The facility failed to clean and sanitize food-contact surfaces of equipment, affecting all residents. The census was 23.
Report Facts
Facility census: 23
Inspection Report
Plan of Correction
Census: 26
Deficiencies: 1
Date: May 19, 2022
Visit Reason
The visit was conducted to assess compliance with fire alarm system regulations and to document deficiencies related to the facility's fire alarm system installation.
Findings
The facility failed to correctly install components of a complete fire alarm system in accordance with NFPA 101 standards. The fire alarm strobes were found not to be synchronized, and the maintenance director was unaware of the deficiency but planned to have it fixed.
Deficiencies (1)
19 CSR 30-86.022(9)(A) Fire Alarm Complete System. The facility failed to correctly install components of a complete fire alarm system as required by NFPA 101, Section 18.3.4, 2000 edition. Fire alarm strobes were not synchronized, which could cause safety issues.
Report Facts
Facility census: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding fire alarm deficiency |
Inspection Report
Plan of Correction
Census: 80
Deficiencies: 2
Date: Mar 17, 2022
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding care for dependent residents, specifically focusing on activities of daily living and personal hygiene.
Findings
The facility failed to ensure dependent residents received necessary services to maintain good personal hygiene, particularly complete perineal care. Observations and interviews revealed inadequate catheter care and inconsistent resident checks, leading to residents being wet and soiled.
Deficiencies (2)
F677 ADL Care Provided for Dependent Residents: The facility failed to provide necessary services to maintain good personal hygiene, including complete perineal care, affecting two sampled residents.
A4076 Clean, Dry, Odor Free: The facility did not ensure residents were clean, dry, and free of offensive body and mouth odor, as evidenced by the issues noted in F677.
Report Facts
Facility census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Johnson | Administrator | Signed the report and plan of correction |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 15, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on 7/15/21 to assess compliance with CMS and CDC guidelines.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Census: 77
Deficiencies: 3
Date: Jun 2, 2021
Visit Reason
The abbreviated survey was conducted as an Immediate Jeopardy (IJ) investigation beginning on 2021-04-29 due to complaints related to resident care and safety.
Findings
The facility failed to assess, treat, and reassess a resident after a fall resulting in fractures and pain. The facility also failed to ensure the resident environment was free of accident hazards related to mechanical lift chair use and failed to maintain safe operating conditions of essential equipment such as low air loss mattresses.
Deficiencies (3)
F684 Quality of Care: The facility failed to assess, treat, and reassess a resident after a fall on 4/29/21, resulting in fractures and untreated pain. The facility census was 77 at the time.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure the resident environment was free of accident hazards by not properly assessing residents' ability to safely use a mechanical lift chair. This affected one resident who fell and could not stand.
F908 Essential Equipment, Safe Operating Condition: The facility failed to ensure staff properly used and checked settings on low air loss mattresses for three residents, including failure to provide a policy on mattress use.
Report Facts
Facility census: 77
Facility census: 73
Residents reviewed for mechanical lift chair safety: 15
Residents with low air loss mattresses reviewed: 3
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 5
Date: Mar 10, 2021
Visit Reason
The inspection was conducted as a COVID-19 focused emergency preparedness survey and complaint investigation related to medication administration errors and quality of care issues.
Complaint Details
The complaint investigation substantiated medication errors affecting Resident #1, including missed antibiotic doses, and quality of care issues related to untreated constipation and inadequate call system responsiveness.
Findings
The facility failed to prevent significant medication errors affecting one resident and failed to provide adequate quality of care related to treatment of constipation and call system responsiveness. Deficiencies were noted in medication administration and resident care practices.
Deficiencies (5)
F760 Residents are free of significant medication errors. The facility failed to prevent significant medication errors when they failed to administer all prescribed antibiotics to one resident, resulting in missed doses.
A4054 Safe and effective medication system. This regulation was not met as evidenced by medication errors described in F760.
A4074 Nursing care per resident condition. The facility failed to provide personal attention and nursing care consistent with acceptable nursing practice as referenced by F760.
F684 Quality of care. The facility failed to ensure one resident received treatment and care in accordance with professional standards, resulting in untreated constipation and hospital admission.
F919 Resident call system. The facility failed to maintain a call system that allowed residents to call for staff assistance, with missing call lights and inadequate staff response.
Report Facts
Facility census: 78
Facility census: 79
Number of missed antibiotic doses: 2
Number of antibiotic doses ordered: 20
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 19, 2021
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted from 2/11/21 through 2/19/21 to assess compliance with CMS and CDC recommended practices and relevant regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Deficiencies: 0
Date: Dec 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from December 8, 2020 to December 16, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR § 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 4, 2020
Visit Reason
A COVID-19 focused infection control and emergency preparedness survey was conducted on August 3 and August 4, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Census: 74
Deficiencies: 2
Date: Jun 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted from June 25 to June 30, 2020, to assess infection prevention and control measures related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness but failed to ensure staff provided care in a manner to prevent infection transmission. Deficiencies were noted in the use of personal protective equipment (PPE), hand hygiene, signage, and screening procedures related to COVID-19.
Deficiencies (2)
F880 Infection Prevention and Control: The facility failed to ensure staff used PPE correctly for residents who tested positive for COVID-19, including proper donning and doffing techniques and hand hygiene. The facility also failed to screen all residents returning from outside medical appointments for COVID-19 exposure.
A4085 Infection Control/Communicable Disease: The facility did not meet the requirement to report communicable diseases to the Missouri Department of Health within seven days as required by state regulations.
Report Facts
Resident census: 74
Number of sampled residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine Horne | Administrator | Signed the inspection report and plan of correction |
| Unit Manager | Registered Nurse | Interviewed regarding PPE availability and use on the COVID-19 unit |
| Director of Nursing | Director of Nursing | Interviewed regarding signage and screening procedures for COVID-19 unit |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 4, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted from June 2 to June 4, 2020, to assess the facility's compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 13
Date: Feb 27, 2020
Visit Reason
The inspection was the annual survey of the Living Community of St Joseph to assess compliance with federal regulations and state requirements.
Findings
The facility was found to have multiple deficiencies including failure to annually inform residents of their rights, inadequate bed rail safety assessments, failure to provide written notices of transfer or discharge, incomplete comprehensive care plans, medication errors, infection control issues, and quality of care concerns.
Deficiencies (13)
F572 Notice of Rights and Rules: Facility failed to annually inform residents of their rights as evidenced by interviews and record reviews.
F604 Right to be Free from Physical Restraints: Facility failed to provide safety for residents by not following bed rail use policy and not providing bed rail protectors for legacy beds.
F623 Notice Requirements Before Transfer/Discharge: Facility failed to provide written notices of transfer or discharge to residents or responsible parties.
F656 Develop/Implement Comprehensive Care Plan: Facility failed to develop comprehensive person-centered care plans for residents including measurable objectives and timely updates.
F658 Services Provided Meet Professional Standards: Facility failed to provide care and treatment in accordance with professional standards for 1 of 18 sampled residents.
F684 Quality of Care: Facility failed to notify the medical director of residents' changes in condition resulting in delay in medical treatment.
F686 Treatment/Services to Prevent/Heal Pressure Ulcers: Facility failed to implement measures to treat and prevent pressure ulcers for one resident.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to ensure resident safety when staff stored unsecured oxygen in one resident's closet.
F693 Tube Feeding Management/Restore Eating Skills: Facility failed to provide appropriate care and services to one resident with tube feeding.
F759 Free of Medication Error Rates 5 Percent or More: Facility failed to ensure staff administered medications with a medication error rate less than 5 percent.
F761 Label/Store Drugs and Biologicals: Facility failed to discard outdated medications and properly label and store medications.
F809 Frequency of Meals/Snacks at Bedtime: Facility failed to ensure residents were offered a bedtime snack as required.
F880 Infection Prevention & Control: Facility failed to provide care to prevent infection and failed to follow hand hygiene and glove use policies.
Report Facts
Facility census: 90
Medication error rate: 8
Medication errors: 2
Residents affected by transfer notice deficiency: 2
Residents affected by care plan deficiency: 2
Residents affected by infection control deficiency: 5
Residents affected by pressure ulcer deficiency: 1
Residents affected by unsecured oxygen deficiency: 1
Residents affected by medication storage deficiency: 4
Residents affected by bedtime snack deficiency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christine E. Rine | Administrator | Signed the plan of correction on 03/20/20. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 27, 2020
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility met the applicable provisions of the Life Safety Code. No deficiencies were cited in the Emergency Preparedness portion or state licensure inspection.
Inspection Report
Routine
Census: 90
Deficiencies: 13
Date: Feb 27, 2020
Visit Reason
Routine inspection of Living Community of St Joseph nursing home to assess compliance with resident rights, restraint use, discharge notification, care planning, medication administration, oxygen therapy, pressure ulcer care, infection control, and other regulatory requirements.
Findings
The facility failed to annually inform residents of their rights, improperly managed bed rail use without proper assessment or consent, failed to provide timely discharge notices, lacked comprehensive care plans for dialysis and hospice, did not follow physician orders for wound care and hypoglycemia management, failed to administer oxygen therapy correctly, delayed notification and treatment for a resident with mental and physical decline, failed to provide appropriate pressure ulcer care, stored oxygen tanks unsafely, improperly administered medications via PEG tube, had medication administration errors, failed to date and discard expired medications, did not consistently offer bedtime snacks, and failed to follow infection control protocols including hand hygiene and insulin pen cleaning.
Deficiencies (13)
F0572: Facility failed to annually inform residents of their rights as required by policy and regulation.
F0604: Facility failed to ensure safe use of physical restraints and bed rails by not assessing residents, lacking orders and consents, and not using mesh protectors on legacy beds.
F0623: Facility failed to provide timely written discharge notices to residents or their representatives for two sampled residents.
F0656: Facility failed to develop comprehensive care plans including dialysis and hospice coordination for two residents.
F0658: Facility failed to follow physician orders and policies for wound care, hypoglycemia management, and oxygen therapy, resulting in delayed treatment and unsafe oxygen administration.
F0684: Facility failed to notify physician timely and provide appropriate care for a resident with mental and physical decline, resulting in delayed hospital transfer after a fall and brain bleed.
F0686: Facility failed to provide appropriate pressure ulcer care and prevention by not identifying and treating a new unstageable pressure ulcer timely.
F0689: Facility failed to ensure safe storage of oxygen tanks when staff stored unsecured oxygen tanks in a resident's closet.
F0693: Facility failed to follow policies for PEG tube medication administration by not checking gastric residual volume and improperly administering crushed medication causing tube clogging.
F0759: Facility failed to ensure medication administration without errors; two errors observed including improper injection technique and failure to prime insulin pen.
F0761: Facility failed to date multi-dose medication bottles and failed to discard expired medications for multiple residents.
F0809: Facility failed to ensure residents were offered and documented bedtime snacks as required, affecting seven residents.
F0880: Facility failed to implement infection prevention and control practices including hand hygiene, glove changes, and cleaning insulin pen rubber seals, risking infection transmission.
Report Facts
Facility census: 90
Medication error rate: 8
Braden score: 13
Braden score: 15
PEG tube flush volume: 50
PEG tube flush volume: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication administration errors, PEG tube medication administration, wound care, and infection control findings |
| LPN B | Licensed Practical Nurse | Named in oxygen therapy and infection control findings |
| RN B | Registered Nurse | Named in resident mental status decline and wound care findings |
| CNA A | Certified Nurse Aide | Named in incontinent care and infection control findings |
| CNA B | Certified Nurse Aide | Named in incontinent care and infection control findings |
| CNA C | Certified Nurse Aide | Named in incontinent care and infection control findings |
| CNA D | Certified Nurse Aide | Named in incontinent care and infection control findings |
| LPN E | Licensed Practical Nurse | Named in insulin pen cleaning and medication administration error |
| LPN G | Licensed Practical Nurse | Named in resident mental status decline and fall incident |
| PTA A | Physical Therapist Assistant | Named in unsafe oxygen storage |
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 14
Date: Jun 4, 2019
Visit Reason
Annual inspection survey conducted on 06/04/2019 to assess compliance with federal and state regulations for Living Community of St Joseph.
Findings
The facility was found deficient in multiple areas including accounting and records of personal funds, required notices and contact information, resident rights, personal privacy, care standards, infection control, medication administration, food safety, and staffing information. Several residents were found at risk due to these deficiencies.
Deficiencies (14)
F568 Accounting and Records of Personal Funds: Facility failed to prevent commingling of funds when staff transferred residents' personal allowance into the facility's account. Resident trust fund balances were negative or incorrect.
F574 Required Notices and Contact Information: Facility failed to provide accessible information on the location of the State Long-Term Care Ombudsman program and State Survey Agency. Residents were unaware of their rights and how to contact advocacy agencies.
F577 Right to Survey Results/Advocate Agency Info: Facility failed to notify residents of the availability and location of the most recent survey results and did not post results in an accessible location.
F583 Personal Privacy/Confidentiality of Records: Facility failed to ensure visual privacy during personal care for three residents. Some residents no longer remained in the facility but were included in findings.
F658 Services Provided Meet Professional Standards: Facility failed to ensure staff notified physician timely of newly identified skin condition and failed to administer eye drops according to policy for two residents.
F677 ADL Care Provided for Dependent Residents: Facility failed to ensure complete perineal care for two residents requiring staff assistance. Residents remained at risk.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to ensure staff used proper transfer techniques to reduce accidents and injuries during gait belt and mechanical lift transfers for four residents.
F690 Bowel/Bladder Incontinence, Catheter, UTI: Facility failed to provide appropriate catheter care and perineal care for residents with urinary catheters and failed to prevent urinary tract infections in five residents.
F695 Respiratory/Tracheostomy Care and Suctioning: Facility failed to provide proper respiratory care including oxygen tubing and humidifier maintenance for two residents using oxygen therapy.
F732 Posted Nurse Staffing Information: Facility failed to post complete nurse staffing data in a prominent and accessible location for residents and visitors.
F759 Free of Medication Error Rates 5 Percent or More: Facility failed to ensure medication error rate was less than 5%, with an error rate of 14.29% observed in medication administration for sampled residents.
F805 Food in Form to Meet Individual Needs: Facility failed to ensure pureed food was smooth and palatable for one resident, potentially affecting all residents on pureed diets.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility failed to serve potentially hazardous food at safe temperatures and failed to follow manufacture instructions for refrigeration and food storage.
F880 Infection Prevention & Control: Facility failed to use proper infection control techniques, disinfect urine-soiled mattresses, and properly screen residents for tuberculosis. Staff failed to follow infection control procedures.
Report Facts
Deficiencies cited: 13
Resident census: 83
Medication error rate: 14.29
Medication error opportunities: 28
Residents affected by medication errors: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named as responsible party for multiple corrective actions and findings. |
| Administrator/designee | Administrator/designee | Named as responsible party for resident funds and audit monitoring. |
| Assistant Administrator | Assistant Administrator | Named as responsible party for resident council minutes audit and corrective actions. |
| Culinary Manager/designee | Culinary Manager/designee | Named as responsible party for food safety and preparation corrective actions. |
| Unit Coordinators/designee | Unit Coordinators/designee | Named as responsible party for audit findings reporting and infection control monitoring. |
| Resource Nurse | Resource Nurse | Named as responsible party for nurse staffing data posting corrective action. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jun 4, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and Emergency Preparedness regulations.
Findings
The facility met the applicable provisions of the 2012 edition of the Life Safety Code and the Emergency Preparedness portion of the survey did not result in deficiencies. No state licensure deficiencies were cited during this inspection.
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 2
Date: May 30, 2018
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with professional standards and regulatory requirements at the Living Community of St Joseph.
Findings
The facility failed to follow physician orders for one resident regarding the removal of compression stockings while the resident was in bed. Staff did not consistently remove the compression stockings as ordered, placing the resident at risk.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i) The facility failed to follow physician orders for one resident by not removing compression stockings while the resident was in bed.
A4074 19 CSR 30-85.042(67) Nursing Care per Resident Condition The facility did not provide nursing care consistent with the resident's condition as evidenced by failure to meet professional standards in F658.
Report Facts
Facility census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in interview regarding expectation to follow physician orders |
| Licensed Practical Nurse | Licensed Practical Nurse | Named in interview regarding application and removal of compression stockings |
| Certified Nurse Aide | Certified Nurse Aide | Named in interview regarding care plan and application/removal of compression stockings |
Inspection Report
Renewal
Deficiencies: 0
Date: May 3, 2018
Visit Reason
The inspection was conducted as a licensure inspection to assess compliance with state and federal regulations for the Living Community of St Joseph facility.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this inspection.
Inspection Report
Life Safety
Census: 70
Capacity: 96
Deficiencies: 4
Date: May 3, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents, focusing on fire safety and emergency preparedness.
Findings
The facility failed to maintain smoke barrier walls and did not conduct fire drills at varied times within shifts as required by NFPA 101. Deficiencies were found in smoke barrier construction and fire drill procedures, affecting staff readiness and resident safety.
Deficiencies (4)
K372: The facility failed to maintain smoke barrier walls with required fire resistance rating, allowing penetrations that compromised smoke barriers in four of eleven smoke compartments. This affected all residents.
K712: The facility failed to conduct fire drills at varied times within shifts as required by NFPA 101, which could affect staff readiness in an actual fire.
A2061: The facility did not meet the requirement for conducting a minimum of twelve fire drills annually with at least one every three months on each shift, including unannounced drills involving resident evacuation.
A3001: The building was not substantially constructed and maintained in good repair as required by 19 CSR 30-85.032(2).
Report Facts
Facility capacity: 96
Resident census: 70
Fire drills required annually: 12
Fire drills required per shift: 1
Fire drills conducted: 6
Fire drills conducted: 2
Inspection Report
Plan of Correction
Census: 39
Deficiencies: 1
Date: May 3, 2018
Visit Reason
The inspection was conducted to evaluate compliance with evacuation plan requirements for residents needing assistance, specifically focusing on individualized evacuation plans and staff training.
Findings
The facility failed to ensure that Resident #1 had an individualized evacuation plan with specific instructions to safely evacuate. Staff had not practiced evacuation procedures, and no specific staff was assigned to assist Resident #1 during evacuation.
Deficiencies (1)
19 CSR 30-86.045(3)(A)(8) Evacuation Plan-Staff Training. The facility failed to ensure Resident #1 had an individualized evacuation plan with specific instructions to safely evacuate. Staff had not practiced evacuation procedures and no staff was assigned to assist Resident #1.
Report Facts
Facility census: 39
Residents on second floor: 15
Residents using walkers: 22
Residents using wheelchairs: 4
Inspection Report
Life Safety
Census: 31
Deficiencies: 2
Date: Mar 22, 2018
Visit Reason
The inspection was a fire safety inspection conducted to evaluate compliance with heating equipment and electrical wiring regulations.
Findings
Two deficiencies were found: an unapproved portable space heater was in use, and the facility failed to complete the required bi-annual electrical wiring inspection. Both deficiencies affected all 31 residents present at the time of inspection.
Deficiencies (2)
19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable: The facility had an unapproved portable space heater in use, which is prohibited. This deficiency affected all 31 residents.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The facility failed to complete the bi-annual electrical wiring inspection as required. This deficiency affected all 31 residents.
Report Facts
Facility census: 31
Deficiency affected residents: 31
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 2
Date: Feb 7, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulations related to pressure ulcer prevention and treatment at Living Community of St Joseph.
Findings
The facility failed to ensure professional standards of care for a resident with a pressure ulcer, including failure to notify the physician and wound nurse when the wound declined and opened. The resident had a pressure ulcer with signs of infection and sepsis, and staff did not properly document or treat the wound according to protocols.
Deficiencies (2)
F686: The facility failed to notify the physician and wound nurse when Resident #1's pressure ulcer declined and opened, and did not properly document wound measurements or clinical status. The resident's wound showed signs of infection and sepsis, and treatment orders were delayed.
A4082: The facility did not meet requirements for pressure sore prevention and treatment as referenced by F686.
Report Facts
Facility census: 72
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Becky Hampton | Assistant Administrator | Signed the plan of correction |
| Physician A | Provided assessment and treatment orders for Resident #1's pressure ulcer | |
| RN A | Registered Nurse | Wound nurse involved in wound care and documentation |
| LPN A | Licensed Practical Nurse | Resident's nurse who provided care and reported on wound status |
| RN B | Registered Nurse | Provided skin risk summary |
| RN C | Registered Nurse | Provided pressure ulcer/wound records |
| RN D | Registered Nurse | Resident's nurse who reported wound odor and notified RN A |
| LPN B | Licensed Practical Nurse | Provided care and reported on resident's condition |
| Director of Nursing | DON | Provided interview and information on wound care notification procedures |
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