Inspection Reports for
Nazareth Living Center
2 NAZARETH LN, SAINT LOUIS, MO, 63129-7600
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
11.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
40% occupied
Based on a January 2026 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Date: Jan 8, 2026
Visit Reason
The inspection was conducted due to concerns about the facility's failure to ensure treatments and medications were administered as ordered for sampled residents.
Complaint Details
The investigation was complaint-related, focusing on missed wound treatments and medication administration errors. The complaint was substantiated with findings of incomplete treatments and missed medications without proper documentation or notification.
Findings
The facility failed to administer treatments and medications as ordered for two residents, including incomplete wound care treatments and missed medication doses. Staff did not document incomplete treatments being completed on alternate shifts, and there was a lack of notification to the Director of Nursing and physician regarding missed medications.
Deficiencies (1)
Failure to ensure treatments and medications were administered as ordered for Resident #4 and Resident #2.
Report Facts
Census: 93
Medication doses not administered: 9
Wound treatment incomplete days: 4
Wound size: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Performed wound care treatment and provided interview about treatment completion |
| LPN B | Licensed Practical Nurse | Night shift nurse aware of missing medication but unable to explain unavailability |
| Director of Nurses | Director of Nursing | Interviewed regarding expectations for treatment completion and notification of missed medications |
| Resident's physician and Medical Director | Physician and Medical Director | Interviewed regarding expectations for medication administration and notification |
| Administrator | Administrator | Interviewed regarding expectations for staff to complete physician orders |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Date: Dec 16, 2025
Visit Reason
The inspection was conducted due to a complaint related to a resident accident during transportation in the facility's medical van, where a resident flipped backward in their wheelchair.
Complaint Details
The visit was complaint-related due to an incident where Resident #3 fell backward in their wheelchair during transport in the medical van. The complaint was substantiated as the facility failed to follow its policy of transporting only one wheelchair-bound resident at a time due to limited straps in the van.
Findings
The facility failed to ensure residents were free from accidents during transportation by not properly securing wheelchair straps, resulting in one resident falling backward in their wheelchair. The facility in-serviced staff on proper wheelchair positioning and the policy of transporting only one wheelchair-bound resident at a time in the medical van.
Deficiencies (1)
Failed to ensure residents are free from accidents when staff failed to properly secure straps in the facility's van during transportation, resulting in one resident flipping backward in their wheelchair.
Report Facts
Census: 101
Number of wheelchair straps in medical van: 6
Date of resident fall incident: Dec 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Van Driver A | Van Driver | Driver during the incident who transported two wheelchair-bound residents simultaneously |
| Van Driver D | Van Driver | Interviewed about facility policy on transporting wheelchair-bound residents |
| Executive Director | Interviewed regarding facility's awareness of van strap limitations and staff in-service |
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 1
Date: Nov 17, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards following an incident where a resident sustained a head injury that was not immediately reported or properly documented by staff.
Findings
The facility failed to ensure one resident received care consistent with professional standards when staff delayed reporting a large bruise and abrasion to the resident's head, resulting in delayed assessment, care, and notification to family and physician. Documentation and communication failures were noted among staff.
Deficiencies (1)
Failure to report and document a resident's head injury immediately, delaying assessment and care.
Report Facts
Sample size: 3
Residents affected: 1
Census: 88
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse's Aide A | Certified Nurse's Aide | Named in relation to failure to report resident injury |
| Licensed Practical Nurse D | Licensed Practical Nurse | Involved in assessment and interview regarding injury reporting |
| Director of Nursing | Director of Nursing | Interviewed regarding staff reporting expectations |
| Administrator | Administrator | Interviewed regarding expectations for injury reporting and documentation |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 4
Date: Jul 29, 2025
Visit Reason
The inspection was conducted due to allegations of misappropriation of resident funds by a staff member and concerns about medication administration and wound care.
Complaint Details
The investigation was complaint-driven based on allegations of financial exploitation by staff and concerns about medication administration and wound care.
Findings
The facility was found to have failed to prevent misappropriation of resident funds by a Certified Nurse Aide (CNA K) who used a resident's debit card without consent. Additionally, the facility failed to administer physician-ordered medications and treatments for multiple residents, including failure to notify physicians and resident representatives. The facility also failed to provide appropriate wound care, resulting in wound dehiscence and the need for hospital transfer. Furthermore, the facility did not maintain accurate controlled substance records and counts, with multiple discrepancies and missing nurse signatures.
Deficiencies (4)
Failure to protect residents from misappropriation of funds by staff member CNA K who used resident's debit card without consent.
Failure to administer physician-ordered medications and notify physicians and resident representatives for three residents, including failure to follow medication parameters.
Failure to provide appropriate wound care and follow physician orders for wound vac therapy, resulting in wound dehiscence and hospital transfer.
Failure to maintain accurate controlled substance records and counts, with multiple discrepancies and missing nurse signatures.
Report Facts
Amount misappropriated: 90
Resident census: 84
Missing nurse signatures: 42
Missing nurse signatures: 12
Missing nurse signatures: 38
Missing nurse signatures: 25
Missing nurse signatures: 91
Missing nurse signatures: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA K | Certified Nurse Aide | Named in misappropriation of resident funds and financial exploitation findings |
| LPN B | Licensed Practical Nurse | Named in medication administration and controlled substance count findings |
| CM F | Clinical Manager | Named in wound care and medication administration findings |
| NP D | Nurse Practitioner | Named in medication administration and notification findings |
| LPN H | Licensed Practical Nurse | Named in medication administration findings |
| LPN G | Licensed Practical Nurse | Named in medication administration findings |
| CMT C | Certified Medication Technician | Named in medication administration findings |
| CMT E | Certified Medication Technician | Named in medication administration findings |
| LPN A | Licensed Practical Nurse | Named in controlled substance count findings |
Inspection Report
Plan of Correction
Census: 99
Deficiencies: 1
Date: Jun 13, 2025
Visit Reason
The document is a plan of correction submitted by Nazareth Living Center following a deficiency related to medication orders not being followed during a survey conducted on 06/13/2025.
Findings
The facility failed to follow physician's medication orders for two of six sampled residents, resulting in missed medications on the evening shift of 05/26/2025. Interviews revealed staffing and scheduling issues that contributed to the failure to administer medications.
Deficiencies (1)
19 CSR 30-86,047(47)(A) Physicians Orders Followed: The facility did not administer medications as ordered for two residents, missing multiple doses on the evening shift of 05/26/2025 due to staffing coverage failures.
Report Facts
Census: 99
Completion date: Jun 3, 2025
Completion date: Jul 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Interviewed regarding medication pass and staffing on 05/26/2025 |
| Director of Human Recourses | Interviewed about staffing scheduling and Administrator authority | |
| Administrator | Interviewed about staffing coverage and medication pass issues | |
| CMT D | Certified Medication Technician | Interviewed about refusal to cover medication pass shift on 05/26/2025 |
Inspection Report
Plan of Correction
Census: 57
Deficiencies: 2
Date: Apr 15, 2025
Visit Reason
The inspection was conducted to investigate deficiencies related to individualized service plans and resident condition/medication review at Nazareth Living Center.
Findings
The facility failed to develop individualized service plans for residents and did not document incidents involving residents adequately. The resident's ISP did not address key behaviors and needs, and the facility failed to document incidents of residents going into other residents' rooms and laying on top of them.
Deficiencies (2)
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop: The facility failed to develop individualized service plans for two sampled residents, including resident needs and services to be provided by staff.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: The facility failed to document a resident's incident of going into another resident's room and laying on top of the other resident in the medical record for two sampled residents.
Report Facts
Census: 57
Inspection Report
Routine
Census: 93
Deficiencies: 17
Date: Mar 14, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements, including resident care, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to notify the Ombudsman of resident transfers, failure to develop baseline care plans within 48 hours of admission, incomplete care plans, medication management errors, inadequate infection control practices, failure to properly assess and document side rail use, and failure to ensure timely medication administration and pain management.
Deficiencies (17)
Failure to notify the State Long-Term Care Ombudsman of resident transfers and discharges and failure to provide written notice to one resident and/or representative.
Failure to develop and implement baseline care plans within 48 hours of admission for three residents.
Failure to develop and implement complete care plans addressing specific resident needs including side rails, urinary catheters, and hospice care.
Failure to provide services meeting professional standards including holding medications without notifying physicians, medication availability issues, and insufficient pharmacy refill tracking.
Failure to provide adequate activities of daily living care including skin care, nail trimming, and facial hair grooming for three residents.
Failure to provide appropriate treatment and care for a resident with recent hip surgery including lack of treatment orders and delayed dressing changes.
Failure to provide appropriate catheter care including lack of catheter orders and failure to flush catheter as ordered.
Failure to ensure safe and appropriate respiratory care including lack of physician orders for oxygen tubing and humidifier changes and failure to reinstate oxygen orders after hospital stay.
Failure to provide safe and appropriate pain management for three residents including delayed medication administration and failure to assess and document pain.
Failure to assess, obtain consent, obtain physician orders, and include in care plans the use of bed/side rails for two residents.
Failure to establish a system of record for controlled drugs with sufficient detail to enable accurate reconciliation for three medication carts.
Medication error rate of 38.71% observed including crushing enteric coated tablets, failure to instruct resident to rinse after inhaler use, and failure to administer ordered medications.
Failure to ensure residents are free from significant medication errors by not obtaining prescribed antibiotic and antiviral medications in a timely manner.
Failure to label and store drugs and biologicals in accordance with professional principles including failure to maintain medication refrigerator temperature logs and secure medication storage boxes.
Failure to inform residents or representatives of their right to refuse arbitration agreements and failure to document resident choices on arbitration agreements.
Failure to adequately develop and implement infection control practices including failure to follow Enhanced Barrier Precautions policy and failure to wear appropriate PPE for residents on contact precautions.
Failure to complete routine inspections of bed/side rails to identify possible areas of entrapment and ensure side rails are secure for two residents.
Report Facts
Residents affected: 21
Census: 93
Medication error rate: 38.71
Controlled substance count shifts missing signatures: 11
Controlled substance count shifts with only one signature: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN N | Licensed Practical Nurse | Discussed medication delays and emergency kit availability |
| CMT J | Certified Medication Technician | Observed preparing and administering medications, discussed medication errors |
| DON | Director of Nursing | Provided expectations on medication administration, infection control, narcotic counts, and side rail assessments |
| Administrator | Facility Administrator | Provided expectations on infection control, arbitration agreements, and side rail inspections |
| CNA F | Certified Nursing Assistant | Observed providing peri-care and discussed ADL care |
| LPN A | Licensed Practical Nurse | Discussed medication administration timing, pain management, and oxygen therapy |
| CMT K | Certified Medication Technician | Discussed side rail assessments and medication reorder processes |
| Case Manager | Discussed arbitration agreement process with residents | |
| Wound Nurse | Discussed wound care and pain management | |
| Environmental Services Director | Discussed side rail installation and maintenance | |
| Lead CNA G | Certified Nursing Assistant | Discussed infection control practices |
| LPN I | Licensed Practical Nurse | Discussed narcotic counts and medication administration |
| CMT T | Certified Medication Technician | Discussed medication administration timing |
Inspection Report
Plan of Correction
Census: 101
Deficiencies: 2
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to assess compliance with fire safety and electrical wiring regulations, including the functionality of the communication system in the area of refuge and the inspection of electrical wiring every two years.
Findings
The facility failed to provide a working two-way communication system and proper signage in the area of refuge, affecting 101 out of 101 residents. Additionally, the facility did not ensure electrical wiring was inspected every two years by a qualified electrician.
Deficiencies (2)
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements. The facility failed to provide a two-way communication system and signage in the area of refuge, affecting 101 residents. The call button did not operate properly when tested multiple times.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to ensure electrical wiring was inspected every two years by a qualified electrician. The last inspection was on June 16, 2022.
Report Facts
Facility census: 101
Residents affected: 101
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding repair of call boxes and electrical inspection | |
| EVS Director | Involved in plan of correction and monitoring communication system and signage | |
| Housing Director | Contacted electrician to locate inspection certificate |
Inspection Report
Routine
Census: 87
Deficiencies: 1
Date: Jul 24, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, specifically to ensure that daily weights were obtained as ordered for residents, including Resident #1.
Findings
The facility failed to ensure daily weights were obtained as ordered for Resident #1, with missing documentation on multiple dates. The Interim Director of Nursing and Administrator confirmed staff responsibility to follow physician orders and document weights.
Deficiencies (1)
Failure to ensure daily weights were obtained as ordered for Resident #1.
Report Facts
Resident sample size: 6
Census: 87
Missing weight documentation dates: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Director of Nursing | Interviewed regarding staff responsibility to follow physician orders and document weights | |
| Administrator | Interviewed regarding staff responsibility to follow physician orders and document weights |
Inspection Report
Plan of Correction
Census: 99
Deficiencies: 9
Date: Mar 15, 2024
Visit Reason
The document is a Plan of Correction submitted by Nazareth Living Center following a state inspection conducted on 03/15/2024. It addresses deficiencies cited during the inspection related to fire safety, tuberculosis screening, community-based assessments, individualized service plans, protective oversight, hand hygiene, resident rights, advance directives, and personal inventory.
Findings
The inspection found multiple deficiencies including failure to post required fire safety signs, incomplete tuberculosis screening for residents and staff, incomplete community-based assessments and individualized service plans, inadequate protective oversight, improper hand hygiene practices, failure to review resident rights annually, incomplete advance directive reviews, and missing personal inventory sheets for residents. The census at the time was 99 residents.
Deficiencies (9)
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements: The facility failed to post required signs and instructions for the Area of Refuge in multiple locations, affecting all residents.
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure required two-step tuberculosis screening tests were completed for sampled residents and employees.
19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day: The facility failed to complete all sections of the community-based assessment for sampled residents within required timeframes.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop: The facility failed to update individualized service plans for sampled residents following falls and other incidents.
19 CSR 30-86.047(35) Protective Oversight: The facility failed to provide protective oversight 24 hours a day for residents with access to operational ovens on one day of observation.
19 CSR 30-87.030(2) Wash Hands/Arms & Clean Fingernails: Staff failed to wash hands and/or change gloves properly during meal preparation, potentially affecting all residents.
19 CSR 30-88.010(4) Resident Rights-Admission/Annual Review: The facility failed to review resident rights annually with residents or their representatives for six of ten sampled residents.
19 CSR 30-88.010(10) Advance Directive Requirements: The facility failed to review advance directives annually for six of ten sampled residents.
19 CSR 30-88.010(36) Personal Clothing/Possessions: The facility failed to complete personal inventory sheets for seven of ten sampled residents.
Report Facts
Census: 99
Deficiencies cited: 9
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 11
Date: Oct 26, 2023
Visit Reason
The inspection was conducted as part of the annual survey and included review of compliance with regulations related to resident care, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to make survey results readily available to residents, failure to provide required Medicare notices, incomplete resident care plans, inadequate eating assistance, failure to prevent resident elopement, medication management deficiencies including narcotic counts and pharmacist review follow-up, improper medication storage and labeling, failure to implement infection control practices, and failure to ensure timely administration of ordered respiratory treatments.
Deficiencies (11)
Failed to make available the results of the most recent annual survey and abbreviated surveys in a place readily accessible to residents and representatives.
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice or denial letter at initiation, reduction, or termination of Medicare Part A benefits for two residents.
Failed to ensure resident care plans were complete, accurate, reviewed, and revised by the interdisciplinary team after assessments for five sampled residents.
Failed to provide eating assistance to one resident for two observed meals.
Failed to ensure appropriate supervision to prevent elopement for one resident who left the facility unsupervised and was found injured off campus.
Failed to establish a system of record for controlled drugs with sufficient detail to enable accurate reconciliation for three controlled substance shift change count sheets.
Failed to ensure pharmacist reports of medication irregularities were communicated and acted upon, and failed to maintain policies for monthly drug regimen review including time frames and urgent action steps.
Failed to limit orders for psychotropic medications to 14 days unless documented rationale for extension, failed to attempt gradual dose reductions or document contraindications, and failed to document non-pharmacological interventions prior to administration.
Failed to ensure one resident received ordered respiratory treatments timely; medication not available and not administered for six opportunities.
Failed to ensure drugs and biologicals were labeled and stored according to accepted professional principles; included expired medications and unlabeled or undated opened insulin pens.
Failed to follow infection prevention and control practices including failure to change gloves, perform hand hygiene, and sanitize shared medical equipment during resident care and transfer.
Report Facts
Census: 86
Controlled substance shift count blanks: 25
Controlled substance shift count blanks: 53
Controlled substance shift count blanks: 49
Pharmacist recommendations to physician: 33
Pharmacist recommendations to nursing: 7
Pharmacist recommendations to physician: 36
Pharmacist recommendations to nursing: 54
Pharmacist recommendations to physician: 23
Pharmacist recommendations to nursing: 41
Pharmacist recommendations to physician: 16
Pharmacist recommendations to nursing: 11
Pharmacist recommendations to physician: 14
Pharmacist recommendations to nursing: 11
Pharmacist recommendations to physician: 17
Pharmacist recommendations to nursing: 11
Expired Heparin vials: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Provided care to Resident #82 and observed with deficient infection control practices |
| CNA B | Certified Nursing Assistant | Provided care to Resident #82 and observed with deficient infection control practices |
| Nurse E | Nurse | Described narcotic count procedures and medication administration |
| CMT H | Certified Medication Technician | Observed performing medication pass and narcotic counts |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication management and infection control |
| Administrator | Facility Administrator | Interviewed regarding elopement and medication management deficiencies |
| Executive Director | Executive Director | Interviewed regarding elopement and medication management deficiencies |
| Clinical Nurse Manager O | Clinical Nurse Manager | Interviewed regarding admission review and elopement risk |
| Nurse K | Nurse | Interviewed regarding medication cart checks and resident care |
| Concierge L | Concierge | Found eloped resident off campus and reported incident |
| Medical Director | Medical Director | Interviewed regarding expectations for elopement prevention and medication management |
| CNA J | Certified Nursing Assistant | Observed feeding assistance issues with Resident #44 |
| CNA M | Certified Nursing Assistant | Reported resident behavior and care observations |
| Nurse I | Nurse | Interviewed regarding medication refrigerator and resident care |
| Director of Environmental Services | Director of Environmental Services | Interviewed regarding cleaning responsibilities for mechanical lifts |
| MDS Reimbursement Coordinator | MDS Reimbursement Coordinator | Interviewed regarding care plan responsibilities |
| Clinical Reimbursement Coordinator | Clinical Reimbursement Coordinator | Interviewed regarding care plan responsibilities |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure appropriate supervision and safety measures for a resident at risk of wandering and elopement.
Complaint Details
The complaint investigation focused on Resident #96 who was found wandering unsupervised outside the facility, resulting in injury. The facility failed to implement appropriate elopement prevention measures upon admission despite hospital records indicating wandering risk. The resident was found approximately 325 feet from the facility entrance. The facility was notified of the past non-compliance and corrected the deficiency by revising assessment and prevention processes and providing staff training.
Findings
The facility failed to ensure one resident received appropriate supervision for wandering, resulting in the resident leaving the facility unsupervised, sustaining a laceration, and requiring hospital treatment. The facility did not implement elopement prevention interventions upon admission despite hospital records indicating risk. The facility has since revised its elopement risk assessment and prevention procedures and provided staff in-service training.
Deficiencies (2)
Failed to ensure one resident received appropriate supervision for wandering, resulting in elopement and injury.
Failed to ensure residents are free from significant medication errors; one resident did not receive ordered breathing treatments due to medication not being delivered.
Report Facts
Resident census: 86
Distance resident found from facility entrance (feet): 325
Medication administration opportunities missed: 6
Sample size for medication review: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse K | Nurse | Documented resident's fall and transfer to hospital; provided interview about resident's wandering and care |
| Clinical Nurse Manager O | Clinical Nurse Manager | Interviewed regarding review of hospital records and elopement prevention |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration failure and admission procedures |
| Case Management Director | Admission Coordinator | Interviewed about review of hospital information prior to resident admission |
| Concierge L | Independent Living Concierge | Found resident outside facility injured and called 911 |
| Certified Nursing Assistant M | CNA | Provided care to resident and described resident's behavior and confusion |
| Medical Director | Medical Director | Interviewed regarding expectations for communication and protocol adherence |
| Nurse I | Nurse | Interviewed about admission procedures and elopement prevention |
Inspection Report
Plan of Correction
Census: 102
Deficiencies: 5
Date: Aug 14, 2023
Visit Reason
The inspection was conducted to identify deficiencies related to facility safety systems including range hood certification, fire safety systems, area of refuge requirements, extension cords usage, and boiler inspection certification.
Findings
The facility failed to have current certifications and proper maintenance for the range hood extinguishing system, fire alarm system, and boiler inspection. Deficiencies were also found in the area of refuge communication system and use of unapproved multi-plug adapters.
Deficiencies (5)
19 CSR 30-86.022(4)(C) Range Hood Certification. The facility failed to have a current inspection tag on the hood suppression system and the system was not inspected semi-annually as required.
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements. The facility failed to provide a two-way communication system between the area of refuge and a remote monitored area.
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain. The facility failed to ensure the fire alarm system was tested and maintained according to NFPA 72 standards with no semi-annual inspection records found.
19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles. The facility failed to supervise the use of unapproved multi-plug adapters in resident rooms.
11 CSR 40-2.022 Section (4) Current Boiler Inspection. The facility failed to have a current boiler inspection certification for pressure vessels.
Report Facts
Facility census: 102
Water heaters BTU input: 300000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Rusk | Housing Director | Named in relation to plan of correction and interview during inspection |
Inspection Report
Plan of Correction
Census: 135
Deficiencies: 2
Date: Jul 10, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to resident care and documentation at Nazareth Living Center, including failure to notify the resident's physician after a change in condition and failure to maintain proper documentation from an advocate group.
Findings
The facility failed to notify the resident's physician when Resident #1 had a change in condition after a fall and did not document pain assessments or referrals from the advocate group. The census at the time of inspection was 135 residents.
Deficiencies (2)
19 CSR 30-86.047(37) Appropriate Action & Notification: The facility failed to notify the resident's physician when Resident #1 had a change in condition after a fall. The census was 135.
19 CSR 30-86.047(58)(B) Resident Condition/Medication Review: The facility failed to ensure all documentation from the advocate group was in the medical record for Resident #1. The census was 135.
Report Facts
Census: 135
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 1
Date: May 2, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely skin assessments and monitoring for a resident with known lower leg circulation issues, which resulted in necrotic toes and a wound.
Complaint Details
The investigation was complaint-related due to failure in skin assessment and monitoring. The resident was admitted with intact skin but developed necrotic toes and a wound that were not identified timely by facility staff. The resident was hospitalized and later elected hospice care. The complaint was substantiated with actual harm to the resident.
Findings
The facility failed to ensure appropriate treatment and care according to professional standards for a resident admitted with intact skin but later developed necrotic toes and a wound due to poor monitoring. The resident was admitted to the hospital with actual harm. The facility's skin assessment policies and procedures were reviewed and found to have gaps in documentation and timely assessments.
Deficiencies (1)
Failure to provide timely skin assessments and monitoring for a resident with lower leg circulation issues, resulting in necrotic toes and a wound.
Report Facts
Census: 88
Dates of skin assessments: 1
Dates of hospital admission: 1
Braden Scale Score: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Hospital Registered Nurse | Provided information about resident's condition and hospital admission on 4/29/23 |
| RN B | Hospital Registered Nurse | Cared for resident on 4/30/23 and described resident's foot condition and pain management |
| Occupational Therapist D | Occupational Therapist | Reported resident missed therapy sessions due to fatigue and noted no foot pain during sessions |
| Wound Nurse | Facility Wound Nurse | Assessed resident's skin on 4/17/23 and described facility skin assessment procedures |
| Administrator | Facility Administrator | Reported inability to locate shower/bath sheets for resident and described expectations for CNA documentation |
| Director of Nursing | Director of Nursing (DON) | Described CNA responsibilities for skin assessments and weekly wound nurse assessments |
| RN C | Endoscopy Clinic Registered Nurse | Observed resident's necrotic toes and reported findings leading to hospital admission on 4/28/23 |
Inspection Report
Plan of Correction
Census: 108
Deficiencies: 8
Date: Jun 29, 2022
Visit Reason
The inspection was conducted to identify deficiencies related to tuberculosis screening, personnel records, community-based assessments, individualized service plans, protective oversight, proper care per individual service plan, and toxic material storage at Nazareth Living Center, an assisted living facility.
Findings
The facility failed to ensure required two-step tuberculosis screening for residents and staff, maintain written physician statements for employees, complete community-based assessments and individualized service plans timely, provide protective oversight, deliver proper care per service plans, and secure toxic materials. Multiple residents and employees were found non-compliant with these regulations.
Deficiencies (8)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility failed to ensure required two-step tuberculosis screening for sampled residents and employees. The census was 108.
19 CSR 30-86.047(20)(I) Personnel Record-physician statement: The facility failed to maintain written statements by licensed physicians indicating employees can work in a long-term care facility for two sampled employees. The census was 108.
19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day: The facility failed to complete community-based assessments within five calendar days of admission for four of nine sampled residents. The census was 108.
19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually: The facility failed to complete semi-annual community-based assessments for five of nine sampled residents. The census was 108.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop: The facility failed to develop individualized service plans with resident preferences and goals for eight of nine sampled residents. The census was 108.
19 CSR 30-86.047(35) Protective Oversight: The facility failed to ensure protective oversight 24 hours a day for all residents, including securing operational ovens, steam tables, and dish warmers for three days of observation. The census was 108.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: The facility failed to provide proper care as defined in individualized service plans for six of nine sampled residents. The census was 108.
19 CSR 30-87.020(5) Toxic Material Storage: The facility failed to ensure poisonous or toxic materials were stored locked and separate from residents for three days of observation. The census was 108.
Report Facts
Census: 108
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee T | Licensed Practical Nurse | Named in tuberculosis screening deficiency and plan of correction |
| LPN B | Named in tuberculosis screening deficiency and plan of correction; noted as no longer working at the facility | |
| Cynthia Rabbe | Housing Director | Signed plan of correction document |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jun 6, 2022
Visit Reason
The inspection was conducted to assess compliance with fire alarm system maintenance, fire alarm system inspections and certifications, smoke section partitions, and electrical wiring maintenance at Nazareth Living Center.
Findings
The facility failed to maintain and inspect the complete fire alarm system as required, did not ensure smoke separation doors fully closed and latched, and failed to have electrical wiring inspected every two years. These deficiencies affected all residents present during the inspection.
Deficiencies (4)
19 CSR 30-86.022(9)(C) Fire Alarm System-Test/Maintain. The facility failed to ensure the complete fire alarm system was tested and maintained according to NFPA 72, 1999 edition. This deficiency affected all 48 residents present.
19 CSR 30-86.022(9)(D) Fire Alarm System Inspections/Certifications. The facility failed to have inspections and written certifications of the complete fire alarm system completed annually. This deficiency affected all 48 residents present.
19 CSR 30-86.022(10)(I) Smoke Section Partitions. The facility failed to ensure required smoke separation doors fully closed and latched. This deficiency affected all 60 residents present.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to ensure electrical wiring was inspected every two years by a qualified electrician. This deficiency affected all 108 residents present.
Report Facts
Residents affected: 48
Residents affected: 48
Residents affected: 60
Residents affected: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Robin | Housing Director | Named in relation to corrective actions and interviews regarding deficiencies |
Inspection Report
Plan of Correction
Census: 103
Deficiencies: 3
Date: Jan 6, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to call systems, protective oversight, and policies at Nazareth Living Center, including incidents of resident falls and exit seeking behaviors.
Findings
The facility failed to ensure an alternate call system was available when the electronic notification system was down, resulting in delayed staff response to a resident fall. Protective oversight was inadequate for residents exhibiting exit seeking behaviors. The facility also failed to implement policies to investigate fall incidents and prevent abuse or neglect.
Deficiencies (3)
19 CSR 30-86.032(33) Call Systems Requirements. The facility failed to ensure an alternate system of calling staff was available when the electronic notification system was down, resulting in delayed response to a resident fall and injury.
19 CSR 30-86.047(35) Protective Oversight. The facility failed to provide protective oversight for a resident exhibiting exit seeking behaviors, allowing the resident to leave the premises unsupervised.
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to implement policies to investigate fall incidents to ensure abuse or neglect did not occur for one of five sampled residents.
Report Facts
Resident census: 103
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Richey | Housing Director | Signed the statement of deficiencies on 01/26/2022 |
Inspection Report
Plan of Correction
Census: 106
Deficiencies: 2
Date: Aug 10, 2021
Visit Reason
The inspection was conducted to assess compliance with fire safety and area of refuge requirements at Nazareth Living Center.
Findings
The facility failed to provide a two-way communication system between the area of refuge and a monitored area, and smoke doors in the St. Joseph building did not close properly, potentially allowing smoke and toxic gases to spread.
Deficiencies (2)
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge Requirements: The facility failed to provide a two-way communication system between the area of refuge and a remote monitored area, delaying emergency evacuation.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: The facility failed to ensure smoke doors in the St. Joseph building were self-closing, allowing smoke and toxic gases to potentially spread.
Report Facts
Facility census: 106
Residents affected: 59
Residents affected: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Interviewed regarding communication system and smoke door deficiencies |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 12
Date: Oct 9, 2020
Visit Reason
The inspection was conducted due to allegations of abuse and neglect, including failure to report suspected abuse timely and failure to investigate abuse allegations thoroughly for multiple residents.
Complaint Details
The complaint investigation was triggered by allegations of abuse and neglect, including failure to timely report abuse, failure to investigate abuse allegations, and concerns about medication management, restorative therapy, personal hygiene, infection control, and narcotic counts. The investigation included interviews, record reviews, and observations related to multiple residents.
Findings
The facility failed to timely report alleged abuse to the Department of Health and Senior Services, failed to thoroughly investigate abuse allegations for multiple residents, failed to ensure proper documentation and care related to medication, restorative therapy, personal hygiene, infection control, and narcotic counts. Several residents had uninvestigated or poorly investigated abuse allegations, and staff failed to follow policies on abuse reporting, medication management, restorative therapy, and infection prevention.
Deficiencies (12)
Failed to timely report alleged abuse to the Department of Health and Senior Services within 2 hours after the allegation was made.
Failed to thoroughly investigate abuse allegations for three residents, including failure to interview witnesses and submit investigations to the state agency within 5 days.
Failed to document fluid and meal intake for two residents and failed to obtain daily weights as ordered for one resident.
Failed to provide adequate personal hygiene care including shaving and nail care for two residents.
Failed to provide restorative therapy as ordered for three residents with orders for restorative therapy.
Failed to ensure safe transfers using mechanical lifts, including leaving lift legs closed during transfer and failure to investigate skin tear.
Failed to provide safe and appropriate dialysis care, including lack of dialysis contract, lack of assessments and communication with dialysis center, and failure to educate resident on renal diet.
Failed to maintain accurate and complete narcotic counts, including missing signatures and undocumented counts on narcotic count sheets.
Failed to ensure monthly pharmacy drug regimen reviews were reviewed and acted upon timely, including failure to notify physician and medical director of irregularities.
Failed to implement gradual dose reductions and limit PRN psychotropic medication use to 14 days.
Failed to label insulin flexpens with date opened and resident name legibly and failed to discard insulin flexpens for discharged residents.
Failed to clean/disinfect gait belt and sit to stand lift between resident uses and failed to perform hand hygiene after glove removal during personal care. Also failed to cover clean laundry gowns stored in hallways.
Report Facts
Residents affected by abuse reporting deficiency: 1
Residents affected by abuse investigation deficiency: 3
Residents sampled: 19
Facility census: 81
Narcotic count shifts missing signatures: 9
Narcotic count shifts missing documentation: 7
Narcotic count shifts with illegible counts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Named in improper mechanical lift transfer and failure to document skin tear |
| CNA F | Certified Nursing Assistant | Named in improper mechanical lift transfer and abuse allegation investigation |
| CNA A | Certified Nursing Assistant | Named in failure to clean/disinfect gait belt between resident uses |
| CNA K | Certified Nursing Assistant | Named in failure to clean/disinfect sit to stand lift between resident uses |
| CNA L | Certified Nursing Assistant | Named in failure to perform hand hygiene after glove removal during perineal care |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding multiple deficiencies including abuse reporting, restorative therapy, medication management, and infection control |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including abuse reporting, restorative therapy, medication management, and infection control |
Inspection Report
Plan of Correction
Census: 98
Deficiencies: 4
Date: Jun 4, 2019
Visit Reason
The inspection was a fire safety inspection conducted on June 4, 2019, to assess compliance with fire extinguisher ratings, area of refuge requirements, smoke section protections, and smoke partitioning in the facility.
Findings
The facility failed to ensure fire extinguishers had the required rating and placement, maintain proper two-way communication in areas of refuge, ensure smoke doors and partitions were properly adjusted and closed, and maintain continuous smoke partitions. These deficiencies potentially affected 98 residents.
Deficiencies (4)
19 CSR 30-86.022(3)(C)(1)(2) Fire Extinguishers. The facility failed to ensure fire extinguishers had a rating of at least ten pounds ABC-rated or equivalent within fifteen feet of hazardous areas.
19 CSR 30-86.022(7)(D)(1-8) Area of Refuge. The facility failed to maintain proper two-way communication systems and other requirements in the area of refuge on June 4, 2019.
19 CSR 30-86.022(10)(H) Smoke Sections. The facility failed to ensure smoke doors were properly adjusted to close fully and smoke partitions were continuous from floor to floor and wall to wall.
19 CSR 30-86.022(10)(I) Smoke Section Protection from Hazards. The facility failed to ensure smoke sections were separated by one-hour fire-rated partitions and that doors were self-closing and automatically closed upon fire alarm activation.
Report Facts
Facility census: 98
Deficiency affected residents: 98
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 5
Date: Mar 12, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding deficiencies in community-based assessments, individualized service plans, medication system, toxic material storage, and backflow prevention at Nazareth Living Center Assisted Living.
Complaint Details
The complaint investigation substantiated multiple deficiencies including failure to update assessments and service plans, unsafe medication practices, improper toxic material storage, and inadequate backflow prevention.
Findings
The facility failed to update community-based assessments after significant changes in residents' conditions and did not provide proper care per individualized service plans. The medication system was unsafe with unlocked medication carts and unattended medications. Toxic materials were improperly stored and the facility failed to ensure backflow prevention in the potable water system.
Deficiencies (5)
19 CSR 30-86.047(28)(F)(1)(C) Community Based Assessment-Significant Change: The facility failed to update resident community based assessments after significant changes in condition for two of seven sampled residents.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: The facility failed to provide proper care per individualized service plans for three of seven sampled residents.
19 CSR 30-86.047(46) Safe & Effective Medication System: The facility failed to ensure a safe and effective medication system when staff left medication carts unlocked and unattended with medications accessible to residents.
19 CSR 30-87.020(5) Toxic Material Storage: The facility failed to ensure toxic chemicals were stored in locked cabinets or secured areas inaccessible to residents.
19 CSR 30-87.020(28) Backflow Requirements: The facility failed to ensure an air gap between the ice machine and pipe to prevent backflow of sewage into the ice machine.
Report Facts
Resident census: 71
Number of sampled residents: 7
Number of residents affected by ISP deficiency: 3
Number of residents affected by community based assessment deficiency: 2
Inspection Report
Plan of Correction
Census: 47
Deficiencies: 2
Date: Apr 19, 2018
Visit Reason
The inspection was conducted to assess compliance with regulations regarding individualized evacuation plans and tuberculosis screening for residents and staff at Nazareth Living Center.
Findings
The facility failed to ensure that residents needing more than minimal assistance had individualized evacuation plans in place. Additionally, the facility did not properly screen residents and staff for tuberculosis as required, with missing documentation for TB tests.
Deficiencies (2)
19 CSR 30-86.045(3)(A)(5) Individual Evacuation Plan - The facility failed to ensure a resident needing more than minimal assistance had a written individualized evacuation plan in their individual service plan. The census was 47.
19 CSR 30-86.047(19) TB Screen Residents & Staff - The facility failed to ensure a newly admitted resident and new employee received a two-step tuberculosis test and failed to document TB test results for sampled employees and residents. The census was 47.
Report Facts
Resident census: 47
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