Inspection Reports for
Nazareth Living Center

MO00254963, MO00254825; substantiation not stated in the document.

1 state deficiency for failure to follow physician orders resulting in missed medications for two of six sampled residents; survey documents indicate staffing/scheduling problems contributed to the missed medication administrations.

MO00252477; substantiation not stated in the file.

Two Missouri state licensure deficiencies were cited: one for failure to develop individualized service plans and one for failure to document resident incidents/condition review and medication review.

Two Missouri State Form deficiencies were cited concerning area of refuge communication and signage, and failure to perform required electrical wiring inspections.

Nine Missouri state deficiencies were cited. They address area of refuge signage/diagrams, tuberculosis screening for residents and staff, incomplete community based assessments and individualized service plans, lack of protective oversight for accessible kitchenettes, inadequate hand hygiene/glove use during food preparation, failures to perform annual resident rights and advance directive reviews, and missing personal inventory sheets; one finding notes past noncompliance regarding accessible kitchenettes.

Eleven deficiencies were cited: six federal deficiencies addressing emergency preparedness and life safety (emergency plan update, emergency power/generator planning, fire alarm testing/maintenance, smoke barrier operation, elevator certification/inspection, and door inspection/testing) and five Missouri State Form deficiencies addressing related fire safety and emergency preparedness rules.

Five state licensure deficiencies were cited addressing range hood certification, area of refuge communication, fire alarm testing/maintenance, extension cords/duplex receptacles (unapproved multi-plug adapters), and lack of current boiler inspection certification.

MO00210526; substantiation status not stated in the record.

Two State Form deficiencies were cited related to notification/appropriate action after a resident fall/change in condition and failure to ensure advocate group documentation was included in the medical record for a referred resident.

9 state deficiencies were cited covering tuberculosis screening and staff physician statements, timely and semi-annual community-based assessments, individualized service plans and proper care per ISPs, protective oversight and kitchen safety, resident condition/medication monthly summaries, and toxic material storage.

Four state deficiencies were cited addressing fire alarm testing and maintenance, fire alarm inspections/certifications, smoke separation doors/latching, and electrical wiring inspection/maintenance.

Three state licensure deficiencies were cited addressing call system failures, inadequate protective oversight for an exit-seeking resident, and failure to implement policies/investigations for a resident fall.

2 state deficiencies (both Class II) were cited: a nonworking two-way communication system for areas of refuge and smoke doors that failed to self-close due to a carpet threshold preventing door closure.

Six deficiencies were cited: three federal life-safety K-tag deficiencies addressing exit signage, electrical systems maintenance/testing, and gas/oxygen cylinder storage, and three Missouri licensure violations reflecting oxygen storage, exit sign illumination, and electrical wiring/equipment maintenance.

Four state deficiencies (all Class II) were cited concerning fire extinguisher rating and placement, area of refuge two-way communication, smoke doors/self-closing devices not closing, and smoke partition continuity/open conduit pipes.

Nine deficiencies were cited: four federal Life Safety (K) deficiencies involving the fire alarm system, sprinkler coverage, portable fire extinguishers, and oxygen cylinder storage; and five Missouri state licensure deficiencies addressing oxygen storage, fire extinguishers, fire alarm testing/maintenance, sprinkler system completeness, and evacuation diagrams.

Five state licensure deficiencies were cited addressing community-based assessment (significant changes), individualized service plans, safe medication system, toxic material storage, and backflow/air gap requirements.

Two Missouri state deficiencies were cited: one for a missing individualized evacuation plan in a resident's ISP and one for failures in tuberculosis screening and documentation for residents and staff.

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.

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.

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.

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.

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.

The investigation was complaint-driven based on allegations of financial exploitation by staff and concerns about medication administration and wound care.

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.

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.

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.

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.

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.

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.

Eleven deficiencies were cited: six federal deficiencies addressing emergency preparedness and life safety (emergency plan update, emergency power/generator planning, fire alarm testing/maintenance, smoke barrier operation, elevator certification/inspection, and door inspection/testing) and five Missouri State Form deficiencies addressing related fire safety and emergency preparedness rules.

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.

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.

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.

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.

Six deficiencies were cited: three federal life-safety K-tag deficiencies addressing exit signage, electrical systems maintenance/testing, and gas/oxygen cylinder storage, and three Missouri licensure violations reflecting oxygen storage, exit sign illumination, and electrical wiring/equipment maintenance.

Nine deficiencies were cited: four federal Life Safety (K) deficiencies involving the fire alarm system, sprinkler coverage, portable fire extinguishers, and oxygen cylinder storage; and five Missouri state licensure deficiencies addressing oxygen storage, fire extinguishers, fire alarm testing/maintenance, sprinkler system completeness, and evacuation diagrams.