Inspection Reports for
St Joseph Chateau
811 NORTH 9TH ST, SAINT JOSEPH, MO, 64501-1651
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
209% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
99% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 2
Date: Sep 11, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to allow one resident to return after transfer without documented reasons, and failure to provide required discharge documentation and notifications to the resident's representative.
Complaint Details
Complaint number 2609355 involved allegations that the facility discharged a resident without proper notice, failed to provide required discharge documentation and notifications, and refused to readmit the resident after hospital transfer despite guardian's objections.
Findings
The facility failed to allow a resident to return without documented justification, did not provide a 30-day discharge notice, bed hold policy, discharge summary, or appeal rights information to the resident's guardian, and did not notify the Ombudsman of the discharge. The facility cited safety concerns related to the resident's suicidal ideations as the reason for discharge and transfer.
Deficiencies (2)
Failed to allow one resident to return to the facility without documented reason that the resident's needs could not be met.
Failed to provide a written 30-day notice of discharge, bed hold policy, discharge summary, reason for discharge, statement of appeal rights, or Ombudsman contact information to the resident's representative.
Report Facts
Residents sampled: 5
Residents affected: 1
Facility census: 68
Referrals made: 8
Referrals accepted: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported resident's suicidal ideations and involvement in transfer decisions |
| Social Services Director | Social Services Director (SSD) | Documented resident's requests and coordinated referrals for alternative placement |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Communicated with guardian regarding resident's status and discharge planning |
| Mental Health Hospital RN | Mental Health Hospital RN (A) | Provided information on resident's hospital stay and discharge readiness |
| Corporate Representative | Corporate Representative (CR) | Discussed involuntary discharge and facility liability concerns |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 7, 2025
Visit Reason
The inspection was conducted as a full survey and complaint investigation for the facility St Joseph Chateau.
Complaint Details
No deficiencies were found during the complaint investigation, indicating no substantiated issues.
Findings
No health facility survey deficiencies or state licensure deficiencies were cited as a result of this full survey and complaint investigation.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 7, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Life Safety
Census: 67
Capacity: 69
Deficiencies: 4
Date: May 7, 2025
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety and building construction regulations at St Joseph Chateau.
Findings
The facility was found deficient in maintaining fire resistance ratings of walls, proper operation and documentation of egress doors with special locking arrangements, maintenance and testing of sprinkler systems, and inspection and testing of fire doors. These deficiencies had the potential to affect residents, staff, and visitors.
Deficiencies (4)
K161: Facility staff failed to maintain the fire resistance rating of walls by not repairing openings, including a quarter size hole in a wall near a resident bed. This posed a potential risk to residents and staff.
K222: Facility staff failed to maintain doors in the path of egress in compliance with NFPA 101, including failure to provide documentation on unlocking electronically controlled delayed-egress doors. Three egress doors were found locked with astragals preventing proper exit.
K353: Facility staff failed to maintain one wet pipe sprinkler system free of obstructions, including shelving in resident room closets that blocked sprinkler coverage, risking delayed fire suppression.
K761: Facility staff failed to ensure fire doors and components were inspected and tested annually as required, lacking documentation of the last fire door inspection. This failure could affect safety during emergencies.
Report Facts
Facility census: 67
Facility capacity: 69
Inspection date: May 7, 2025
Inspection Report
Routine
Census: 43
Deficiencies: 1
Date: Aug 27, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with maintaining a safe, clean, and comfortable environment for residents, focusing on pest control and sanitation issues.
Findings
The facility failed to maintain a safe and clean environment, with multiple observations of pest infestations including mice and cockroaches, mold-like substances, damaged building structures, and unsanitary conditions in various areas such as the kitchen, laundry room, basement, and resident rooms. Pest control recommendations and sanitation issues were not adequately addressed.
Deficiencies (1)
Failure to maintain a safe, clean, and comfortable environment including pest control and sanitation issues.
Report Facts
Resident census: 43
Mice removed: 3
Mice removed: 3
Mice removed: 2
Mice removed: 2
Mice removed: 2
Mice removed: 3
Mice removed: 4
Mice removed: 2
Mice removed: 1
Mice removed: 1
Mice removed: 1
Mice removed: 1
Mice removed: 3
Mice removed: 4
Mice removed: 1
Mice removed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide A | Interviewed regarding mouse sightings in the kitchen | |
| Resident #1 | Reported seeing mice in his/her room on multiple occasions | |
| Physical Therapist | Reported seeing mice in halls and therapy office | |
| Occupational Therapist | Reported increased mouse sightings in therapy and dining areas | |
| Activities Director | Reported frequent mouse sightings in activity office | |
| Director of Maintenance | Reported facility currently without maintenance person and awareness of pest control issues | |
| Administrator | Acknowledged pest control issues and expectations for cleanliness |
Inspection Report
Life Safety
Census: 61
Capacity: 61
Deficiencies: 10
Date: Apr 5, 2024
Visit Reason
A Life Safety Code survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Findings
The facility was found to be in noncompliance with several Life Safety Code requirements including kitchen hood system maintenance, smoke detector operation, sprinkler system coverage, smoke barrier integrity, suspended unit heaters safety, fire alarm system testing, evacuation plan implementation, smoking regulations, electrical system maintenance, and gas equipment storage. Deficiencies had the potential to affect all 61 residents.
Deficiencies (10)
K324 Cooking Facilities: The facility failed to ensure the kitchen hood system had monthly checks or maintenance since the start of 2024. The maintenance tag was blank and unverified.
K341 Fire Alarm System - Installation: The facility failed to ensure smoke detectors operated cross-corridor smoke doors within 5 feet of the wall as required by NFPA 101. Observations showed smoke detectors were 8 to 9 feet away from smoke barrier walls.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to complete smoke detection sensitivity testing for 10 of 10 photoelectric smoke detectors. Records showed the last test was in 2022.
K353 Sprinkler System - Maintenance and Testing: The facility failed to ensure sprinkler system coverage included attic and exterior locations. The last 5-year internal inspection was overdue since 2017.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility failed to maintain two smoke barrier walls, including a 6 inch hole in a ceiling tile and lack of fire resistance rating. This affected 19 residents in two smoke zones.
K523 HVAC - Suspended Unit Heaters: The facility failed to ensure two suspended heating units in the attic had safety features to shut down on excessive temperature or ignition failure. This affected all 61 residents.
K711 Evacuation and Relocation Plan: The facility failed to implement a fire plan consistent with NFPA 101, lacking references to calling 911 and smoke compartment evacuation. This affected all 61 residents.
K741 Smoking Regulations: The facility failed to ensure resident and staff smoking was in accordance with NFPA 101. Observations showed ash trays missing and unsafe smoking areas affecting 25 resident smokers.
K918 Electrical Systems - Essential Electric System: The facility failed to maintain the emergency power system and battery-powered lighting. The failure affected all 61 residents.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to properly store compressed oxygen tanks and segregate empty cylinders. This affected all 61 residents.
Report Facts
Residents affected: 61
Resident smokers affected: 25
Inspection Report
Routine
Census: 62
Deficiencies: 16
Date: Apr 5, 2024
Visit Reason
Routine inspection of St Joseph Chateau nursing home to assess compliance with regulatory standards including resident care, environment, medication management, and infection control.
Findings
The facility had multiple deficiencies including failure to ensure dignified care and resident privacy, improper management of resident trust funds, unsanitary and unsafe environmental conditions including odors and pest infestations, medication administration errors, inadequate supervision of residents at risk for choking, failure to prevent significant weight loss, improper use and maintenance of bed rails, failure to timely address pharmacist medication recommendations, and failure to maintain a clean and sanitary kitchen environment.
Deficiencies (16)
Failure to ensure residents were cared for in a dignified way, including failure to cover residents' skin in common areas and failure to provide a dignified dining experience due to noise and odors.
Failure to maintain accurate accounting and monthly reconciliation of resident trust fund accounts.
Facility environment had strong urine odors, stained and damaged flooring and walls, presence of gnats, loose handrails, broken toilets, and unclean conditions in resident rooms and common areas.
Failure to provide timely written notice of transfer or discharge to residents, responsible parties, and the Office of the State Long-Term Care Ombudsman.
Failure to follow professional standards in medication administration including blood sugar monitoring errors, failure to clarify medication orders, and failure to hold medication when order was unclear.
Failure to provide complete perineal and urinary catheter care to dependent residents, including failure to clean all perineal folds and anchor catheter tubing.
Failure to provide supervision while eating for a resident at risk for choking.
Failure to prevent significant weight loss of more than 10% in 3 months for a resident at nutritional risk and on dialysis.
Failure to assess residents for risk of entrapment from bed rails prior to installation, failure to ensure bed dimensions appropriate for resident size and weight, and failure to ensure scheduled maintenance of bed rails.
Failure to monitor and timely address pharmacist medication regimen review recommendations for multiple residents.
Failure to serve food that is palatable, attractive, and at a safe and appetizing temperature; residents complained of cold food and small portions.
Failure to prepare pureed food with appropriate consistency, resulting in food that was too thin and a choking hazard.
Failure to maintain kitchen and food storage areas in a sanitary manner, including dirt and debris on floors, ceilings, vents, and inside freezers; presence of open and undated food packages.
Failure to maintain quarterly Quality Assessment and Assurance (QAA) meetings with required members and consistent attendance.
Failure to follow infection prevention and control standards including handling medications with bare hands and failure to provide annual tuberculosis testing for some residents.
Failure to maintain an effective pest control program to prevent gnats and mice infestations facility-wide, including mice droppings in resident rooms and gnats in multiple areas.
Report Facts
Facility census: 62
Residents affected: 16
Weight loss: 15.38
Weight loss: 10.57
Weight loss: 5.38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication administration and blood sugar monitoring findings |
| CNA A | Certified Nurse Aide | Named in findings related to resident care and supervision |
| CNA B | Certified Nurse Aide | Named in findings related to resident care |
| CMT A | Certified Medication Technician | Named in medication administration and infection control findings |
| DON | Director of Nursing | Named in multiple interviews regarding findings and facility practices |
| Business Office Manager | Named in resident trust fund reconciliation findings | |
| Housekeeping Supervisor | Named in environmental odor and cleanliness findings | |
| Maintenance Director | Named in environmental and bed rail maintenance findings | |
| Administrator | Named in interviews regarding facility management and QAA | |
| Social Services Designee | Named in transfer and discharge notification findings | |
| Registered Dietitian | Named in nutrition and food service findings | |
| Regional Maintenance Supervisor | Named in bed rail maintenance findings | |
| Physical Therapy Assistance A | Named in bed rail assessment findings | |
| Infection Preventionist | Named in infection control findings | |
| Pest Control Manager | Named in pest control findings | |
| Local Exterminator | Named in pest control findings |
Inspection Report
Routine
Census: 63
Deficiencies: 4
Date: Dec 19, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident access to communication, transfer and discharge notification, bed-hold policies, and provision of personal care including bathing and grooming.
Findings
The facility failed to provide continuous phone service affecting resident and healthcare professional communication, did not provide written transfer or discharge notices or bed-hold policy notifications to residents or their representatives, and failed to ensure dependent residents received at least two showers per week as required, with multiple residents missing showers due to staffing issues and refusals.
Deficiencies (4)
Failure to provide continuous phone service from 11/24/23 to 12/10/23, impacting resident and healthcare professional communication.
Failure to provide written notice of transfer or discharge and reasons for transfer to residents or responsible parties for three sampled residents.
Failure to provide written notice of bed-hold policy to residents or their representatives before transfer to hospital for three sampled residents.
Failure to provide at least two showers per week to six sampled residents, with documentation showing multiple missed shower opportunities and refusals.
Report Facts
Facility census: 63
Residents affected by phone service deficiency: 2
Residents affected by transfer/discharge notice deficiency: 3
Residents affected by bed-hold notice deficiency: 3
Residents affected by bathing deficiency: 6
Missed shower opportunities: 8
Missed shower opportunities: 5
Missed shower opportunities: 6
Missed shower opportunities: 5
Missed shower opportunities: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Interviewed regarding phone system issues and shower documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding phone system issues, transfer agreements, bed-hold notices, and shower policies |
| Administrator | Facility Administrator | Interviewed regarding phone system issues, transfer agreements, bed-hold notices, and shower policies |
| CMT A | Certified Medication Technician | Interviewed regarding phone system issues and shower refusals |
| Business Office Manager | Business Office Manager | Interviewed regarding phone system issues |
| RN A | Hospital Nurse | Interviewed regarding inability to contact facility by phone on 11/24/23 |
| CNA A | Certified Nursing Assistant | Interviewed regarding shower provision and refusals |
| CNA B | Certified Nursing Assistant | Interviewed regarding staffing issues affecting shower provision |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 7
Date: Dec 19, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide immediate access to residents via phone and issues with transfer/discharge notices and bed hold policies.
Complaint Details
The complaint investigation substantiated that the facility failed to maintain continuous phone service, affecting resident access and communication. It also found failures in providing required notices for transfers, discharges, and bed hold policies, as well as inadequate assistance with activities of daily living for dependent residents.
Findings
The facility failed to provide continuous phone service affecting resident access and communication with healthcare professionals. The facility also failed to provide proper written notices for transfers/discharges and bed hold policies, and did not ensure adequate assistance with grooming and showers for dependent residents.
Deficiencies (7)
F562 Immediate Access to Resident: The facility failed to provide resident representatives and health care professionals access due to phone service outages from 11/24/23 to 12/10/23 affecting two residents.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide written notice of transfer or discharge to residents or their representatives in a timely and understandable manner for sampled residents.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to provide written notice of bed-hold policy before transferring residents to the hospital for three sampled residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide adequate assistance with grooming and showers to six of eight sampled residents, resulting in poor hygiene and missed shower opportunities.
A4076 Clean, Dry, Odor Free: Residents were not consistently clean, dry, and free of offensive odors as evidenced by poor hygiene and grooming.
A8018 Emergency Discharges: The facility failed to provide timely written notice of emergency discharges to residents or their representatives.
A8034 Telephone-Private Calls: Telephones were not accessible at all times and did not enable residents to make and receive calls privately.
Report Facts
Facility census: 63
Number of residents affected by phone outage: 2
Number of sampled residents for transfer notice: 8
Number of residents transferred to hospital without proper notice: 3
Number of residents with inadequate shower assistance: 6
Number of residents with bed hold notice issues: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding phone service outage and corrective actions | |
| Director of Nursing | DON | Interviewed about phone system issues, transfer protocols, and shower assistance |
| Registered Nurse | RN | Interviewed about phone outages and transfer procedures |
| Business Office Manager | Interviewed about phone system problems | |
| CMT A | Interviewed about phone outages | |
| CNA A | Certified Nursing Assistant | Interviewed about shower refusals and assistance |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 2
Date: Oct 5, 2023
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to notify a resident's primary care physician about a wound contaminated by maggots and concerns about pest control.
Complaint Details
The complaint investigation found that the facility did not notify the primary care physician about a resident's wound with maggots, and the pest control program was ineffective in preventing flies. The complaint was substantiated by observations, interviews, and record reviews.
Findings
The facility failed to notify the primary care physician and medical director of a resident's wound contaminated by maggots and did not maintain an effective pest control program to prevent flies. Multiple interviews and observations confirmed the presence of flies and maggots, and the facility had recently contracted a new pest control company.
Deficiencies (2)
Failure to notify the resident's primary care physician and medical director of a wound contaminated by maggots.
Failure to maintain an effective pest control program to prevent flies.
Report Facts
Facility census: 62
Flies killed by resident: 27
Pest control treatments completed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | Licensed Practical Nurse | Called to the tub room by Hospice Nurse A regarding the wound with maggots |
| PCP/MD A | Primary Care Physician/Medical Director | Notified status regarding the resident's wound with maggots |
| Director of Nursing | Director of Nursing | Interviewed about notification of PCP/MD and wound treatment |
| Administrator in Training | Administrator in Training | Interviewed about awareness of maggots in wound and notification procedures |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 2
Date: Oct 5, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's physician about a wound contaminated by maggots and issues with pest control.
Complaint Details
The complaint investigation found the facility did not notify the resident's physician about a wound contaminated by maggots. The complaint was substantiated based on observations, record review, and interviews.
Findings
The facility failed to notify the primary care physician and medical director about a resident's wound contaminated by maggots. Additionally, the facility did not maintain an effective pest control program, resulting in flies and maggots in resident rooms.
Deficiencies (2)
F580: The facility failed to notify one resident's primary care physician and medical director of a wound contaminated by maggots. The facility census was 62 at the time of inspection.
F925: The facility failed to maintain an effective pest control program to prevent flies and other pests. Observations included multiple flies in a resident's room and maggots in a wound.
Report Facts
Facility census: 62
Flies killed: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported Hospice nurse found maggots and notified physician; stated PCP/MD should have been notified |
| Administrator in Training | Administrator in Training (AIT) | Interviewed about awareness of maggots and PCP/MD notification |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Called to tub room by Hospice Nurse; reported maggots in wound |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 17, 2023
Visit Reason
The inspection was conducted as a routine annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 62
Deficiencies: 1
Date: Aug 17, 2023
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically regarding adherence to COVID-19 related protocols and use of personal protective equipment (PPE) during the SARS-CoV-2 outbreak.
Findings
The facility failed to maintain an effective infection control program during the COVID-19 pandemic, with staff not consistently wearing PPE when entering SARS-CoV-2 positive resident rooms. Several residents were observed not following isolation precautions, and transmission-based precaution signage was often missing. The facility experienced difficulty keeping SARS-CoV-2 positive residents isolated to their rooms.
Deficiencies (1)
Failure to follow facility policy for infection prevention and control program when staff did not wear personal protective equipment (PPE) when entering SARS-CoV-2 positive rooms.
Report Facts
Residents affected: 5
Facility census: 62
SARS-CoV-2 positive residents: 9
Isolation duration: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) A | Observed not wearing N95 mask when entering SARS-CoV-2 positive resident room and adding PPE outside rooms; described infection control training and PPE expectations. | |
| Nurse Aide (NA) A | Entered resident room without PPE with CNA A. | |
| Certified Nurse Aide (CNA) B | Observed pulling out PPE equipment and stated not knowing why staff did not wear N95 masks. | |
| Certified Nurse Aide (CNA) C | Observed serving room tray to resident without PPE. | |
| Infection Preventionist | Described expectations for transmission-based precautions and PPE use, and issues with keeping residents quarantined. | |
| Director of Nursing (DON) | Described hand hygiene expectations, PPE use, isolation procedures, and challenges with resident compliance. | |
| Administrator | Described facility policies on isolation, PPE availability, communication with families, and challenges with resident isolation compliance. |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 2
Date: Aug 17, 2023
Visit Reason
The inspection was conducted due to a complaint investigation related to infection prevention and control practices during a COVID-19 outbreak at the facility.
Complaint Details
The investigation was triggered by a complaint regarding inadequate infection control during a COVID-19 outbreak. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Staff did not consistently wear personal protective equipment (PPE) when entering SARS-CoV-2 positive rooms, and transmission-based precautions were not properly posted or followed.
Deficiencies (2)
F880 Infection Prevention & Control: The facility failed to maintain an infection prevention and control program during a COVID-19 outbreak. Staff did not wear PPE consistently when entering SARS-CoV-2 positive rooms, and transmission-based precautions were not properly posted or followed.
A4086 Infection Control/Communicable Disease: The facility failed to use acceptable infection control procedures to prevent the spread of infection and did not report communicable disease cases to the state within seven days as required.
Report Facts
Facility census: 62
Residents SARS-CoV-2 positive: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Named in relation to infection control findings and plan of correction |
| Director of Nursing | Director of Nursing | Observed interacting with resident regarding mask use and interviewed about infection control practices |
| Certified Nurse Aide A | Certified Nurse Aide | Observed not wearing PPE and interviewed about PPE use |
| Certified Nurse Aide B | Certified Nurse Aide | Observed pulling out PPE and interviewed about PPE use |
| Infection Preventionist | Infection Preventionist | Interviewed about transmission-based precautions and PPE policies |
Inspection Report
Census: 62
Deficiencies: 2
Date: May 25, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding the management of resident funds and timely payment of facility bills.
Findings
The facility failed to keep resident funds separate from operating funds, resulting in negative balances for two residents. Additionally, the facility did not pay city water and sewer bills in a timely manner, leading to a large outstanding balance. The facility lacked policies addressing resident trust funds and timely bill payments.
Deficiencies (2)
Failed to ensure resident funds were kept separate from facility operating funds, resulting in negative balances for two residents.
Failed to ensure payments were issued in a timely manner to the facility's city water and sewer management provider.
Report Facts
Resident census: 62
Resident #1 negative balance: -3159.43
Resident #2 negative balance: -1398.78
Outstanding city sewer balance: 2709.18
Past due penalties: 484.14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding resident funds and utility bill payments; no full name provided | |
| Administrator | Interviewed regarding resident funds and utility bill payments; no full name provided |
Inspection Report
Plan of Correction
Census: 62
Deficiencies: 4
Date: May 25, 2023
Visit Reason
The document is a Statement of Deficiencies related to a survey completed on 05/25/2023 for St Joseph Chateau, detailing regulatory deficiencies found during the inspection.
Findings
The facility failed to keep resident funds separate from operating funds and did not provide policies regarding Resident Trust Funds. Additionally, the facility failed to ensure timely payments to the city water and sewer management provider and lacked policies addressing timely bill payments.
Deficiencies (4)
F567 Protection/Management of Personal Funds: The facility failed to keep resident funds separate from operating funds and did not provide a policy regarding Resident Trust Funds. Two residents had negative balances in the facility's operating account.
F835 Administration: The facility failed to ensure timely payments to the city water and sewer management provider and did not provide a policy addressing timely bill payments.
A4003 Operator/Administrator Responsibilities: The operator failed to assure compliance with applicable laws and rules, including oversight to ensure residents receive appropriate nursing and medical care.
A9010 Discharge Requirement Within 5 Days: The operator failed to provide an up-to-date accounting of resident personal funds and return all personal possessions within five calendar days of discharge.
Report Facts
Facility census: 62
Negative balance Resident #1: -3159.43
Negative balance Resident #2: -1398.78
Billing amounts and penalties: 3761.45
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 1
Date: Apr 26, 2023
Visit Reason
The inspection was conducted to assess compliance with pressure ulcer care and prevention standards at the facility.
Findings
The facility failed to identify, assess, and document a pressure ulcer on the ear of one resident (Resident #1) in a timely and accurate manner. The resident had an open wound caused by oxygen tubing pressure, which was not properly documented or treated, and the physician was not notified as required.
Deficiencies (1)
Failure to identify, assess, and document a pressure ulcer on the ear for one resident.
Report Facts
Census: 61
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide B | Certified Nurse Aide | Reported about the protective sponge on oxygen tubing and resident behavior |
| Registered Nurse B | Registered Nurse | Interviewed regarding awareness of the resident's open wound |
| Director of Nursing | Director of Nursing | Provided information about resident's prior cellulitis treatment and wound notification |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 1
Date: Apr 26, 2023
Visit Reason
The inspection was conducted to assess compliance with pressure ulcer care and prevention protocols, specifically to evaluate the facility's identification, assessment, and documentation of pressure ulcers.
Findings
The facility failed to identify, assess, and document a pressure ulcer on the ear of one resident (Resident #1) out of five reviewed. The resident had an open wound caused by oxygen tubing pressure, which was not properly documented or treated, and the physician was not notified timely.
Deficiencies (1)
Failure to identify, assess, and document a pressure ulcer on the ear of Resident #1.
Report Facts
Facility census: 61
Brief Interview of Mental Status (BIMS) score: 13
Quarterly Minimum Data Set date: Mar 6, 2023
Nurse Aide skin assessment date: Apr 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide B | Certified Nurse Aide | Reported the use and removal of protective sponge on oxygen tubing related to the resident's ear wound |
| Registered Nurse B | Registered Nurse | Unaware of the open wound; stated CNAs should notify nurses immediately of open areas |
| Director of Nursing | Director of Nursing | Reported resident was previously on antibiotics for cellulitis; was made aware of the open area recently |
Inspection Report
Routine
Census: 61
Deficiencies: 2
Date: Apr 26, 2023
Visit Reason
A COVID-19 focused emergency preparedness survey and a routine inspection related to pressure ulcer prevention and treatment were conducted.
Findings
The facility was found to be in compliance with COVID-19 emergency preparedness requirements. However, the facility failed to properly identify, assess, and document a pressure ulcer on one resident, with incomplete assessments and lack of physician notification or treatment orders.
Deficiencies (2)
F686: The facility failed to identify, assess, and document a pressure ulcer on the ear of one resident. The resident's medical record lacked a completed Braden assessment, nursing progress notes, and physician orders for the wound.
A4083: The facility did not meet the requirement to keep residents free from avoidable pressure sores and provide adequate treatment. Refer to F686 for details.
Report Facts
Facility census: 61
Deficiency count: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kara Clark | Administrator | Signed the report and plan of correction |
| Director of Nursing | Interviewed regarding resident's pressure ulcer and treatment |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Mar 1, 2023
Visit Reason
The inspection was conducted due to concerns about the failure of the Wander Guard (WG) system to function properly, which led to resident elopements and safety risks.
Complaint Details
The visit was complaint-related due to the failure of the Wander Guard system to alarm, resulting in Resident #1 eloping from the facility and Residents #2 and #3 exiting without alarms. The complaint was substantiated by observations, record reviews, and interviews.
Findings
The facility failed to keep three sampled residents safe when the WG system did not alarm at the front and patio doors, allowing Resident #1 to elope and Residents #2 and #3 to exit without alarms. The WG bracelets were checked regularly and appeared functional, but the doors did not alarm or lock as expected, compromising resident safety.
Deficiencies (1)
Failure to keep residents safe due to malfunctioning Wander Guard system that did not alarm at doors, resulting in resident elopement and unsafe exits.
Report Facts
Facility census: 60
Number of doors equipped with WG system: 6
BIMS scores: 13
BIMS scores: 3
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided interviews regarding WG system functionality and resident safety | |
| Registered Nurse (RN) A | Documented inability to locate Resident #1 and WG bracelet status | |
| Maintenance Supervisor | Tested WG system weekly and ensured door alarms functioned |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Date: Mar 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the failure of the wander guard system to function properly, resulting in a resident eloping from the facility.
Complaint Details
The complaint investigation substantiated that the wander guard system failed to function properly, resulting in a resident eloping from the facility and being found unharmed five blocks away. The facility's policies and staff practices were reviewed and found deficient.
Findings
The facility failed to keep three sampled residents safe as the wander guard system did not alarm at the front door and patio door, allowing a resident to elope and be found five blocks away. The facility's policies on elopement and wandering were reviewed, and deficiencies were identified in supervision and device functionality.
Deficiencies (2)
F689: The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. The wander guard system did not function properly, allowing a resident to elope and not alarm at exit points.
A4074: The facility did not meet the requirement for twenty-four-hour protective oversight and supervision for residents on voluntary leave, including procedures to inquire about the resident's whereabouts. This deficiency is linked to F689.
Report Facts
Facility census: 60
Dates of resident admission and discharge: Resident #1 admitted 2/24/23 and discharged 2/28/23
BIMS scores: Resident #1 BIMS score 13; Resident #2 BIMS score 3; Resident #3 BIMS score 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding resident elopement and wander guard system functionality | |
| Registered Nurse (RN) | Reported inability to locate resident and observations about wander guard system | |
| Maintenance Supervisor | Interviewed about weekly testing of wander guard system |
Inspection Report
Plan of Correction
Census: 56
Deficiencies: 2
Date: Dec 21, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to the protection and management of residents' personal funds at St Joseph Chateau.
Findings
The facility failed to ensure residents had access to their personal funds, affecting five sampled residents who could not make purchases or send Christmas gifts due to lack of access. The facility's resident funds policy and management practices did not meet regulatory requirements.
Deficiencies (2)
F 567: The facility failed to ensure residents had access to their personal funds, affecting five residents who could not purchase items or send gifts due to restricted access to their money.
A9001: No operator is required to hold, manage, safeguard, or account for personal funds unless required by governmental agency. This regulation was not met, evidenced by the F567 deficiency.
Report Facts
Resident census: 56
Resident #1 account balance: 18.52
Resident #3 account balance: 3036.78
Resident #4 account balance: 1.08
Resident #1 account balance (later): 29.16
Resident #5 account balance: 14688.44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kerry Ulrich | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Routine
Census: 62
Deficiencies: 22
Date: Apr 29, 2022
Visit Reason
Routine inspection of St Joseph Chateau nursing home to assess compliance with resident rights, care, safety, medication administration, infection control, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and respect, inadequate grievance response, incomplete criminal background checks for staff, failure to maintain clean and safe environment, improper medication administration and documentation, failure to provide timely showers and restorative care, improper use and assessment of bed rails, incomplete PASARR screenings, and failure to maintain accurate nurse staffing postings.
Deficiencies (22)
Staff failed to treat residents with dignity and respect during meal service and wheelchair handling.
Facility failed to consider resident group grievances promptly and document responses.
Facility failed to submit increased Resident Trust Fund bond to state for approval.
Facility failed to inform residents of their rights periodically beyond admission.
Facility failed to post complete and accurate local ombudsman contact information.
Facility failed to maintain a clean and safe environment including resident rooms, dining areas, and kitchen.
Facility failed to allow residents to voice grievances, failed to respond in writing, and failed to provide grievance forms.
Facility failed to maintain complete criminal background checks and registry verifications for staff.
Facility failed to conduct a thorough investigation of resident's verbal abuse allegation.
Facility failed to maintain evidence of PASARR Level II screenings for residents requiring them.
Facility failed to complete discharge summary for a discharged resident.
Facility failed to assist resident with activities of daily living including timely showers.
Facility failed to provide restorative nursing program to maintain or improve residents' range of motion.
Facility failed to post accurate nurse staffing information daily.
Facility failed to ensure timely communication and physician action on consultant pharmacist recommendations and failed to discontinue unnecessary medications.
Facility medication administration errors occurred with an error rate of 38.46%, including crushing extended release medications and improper eye drop administration.
Facility failed to discard expired medications and medications of discharged residents.
Facility failed to follow proper infection control practices including hand hygiene during medication administration and perineal care, and failed to maintain staff TB testing records.
Facility failed to assess residents for bed rail safety, obtain informed consent, and ensure proper installation for three residents using bed rails.
Facility failed to ensure nursing staff had appropriate competencies and training to provide safe and effective transfers for residents using mechanical lifts.
Facility failed to ensure food was palatable, attractive, served at safe temperatures, and prepared according to recipes for pureed diets.
Facility failed to store food and maintain kitchen in a sanitary manner, including expired and unlabeled food items, dirty equipment, and poor food handling practices.
Report Facts
Medication errors: 10
Facility census: 62
Medication administration opportunities: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in medication administration and infection control findings |
| LPN B | Licensed Practical Nurse | Named in medication administration and infection control findings |
| NA A | Nurse Aide | Named in transfer and training findings |
| NA C | Nurse Aide | Named in transfer and infection control findings |
| NA D | Nurse Aide | Named in transfer and infection control findings |
| CNA E | Certified Nurse Aide | Named in transfer and infection control findings |
| NA B | Nurse Aide | Named in shower and restorative care findings |
| Cook A | Cook | Named in food preparation and sanitation findings |
| Dietary Manager | Dietary Manager | Named in food service and sanitation findings |
| Administrator | Facility Administrator | Named in multiple interviews and findings |
| Director of Nursing | Director of Nursing | Named in multiple interviews and findings |
| Corporate Clinical Nurse | Corporate Clinical Nurse | Named in multiple interviews and findings |
| Human Resources Coordinator | Human Resources Coordinator | Named in staff background check and TB testing findings |
| CNA/RA A | Certified Nurse Aide/Restorative Aide | Named in restorative care findings |
Inspection Report
Life Safety
Census: 62
Capacity: 69
Deficiencies: 11
Date: Apr 29, 2022
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility failed to meet several Life Safety Code requirements including emergency preparedness policies, tracking of staff and residents during emergencies, maintenance of safe exit discharge paths, fire alarm system functionality, sprinkler system maintenance, and fire extinguisher inspections. Multiple deficiencies were cited related to fire safety equipment, evacuation plans, and training.
Deficiencies (11)
E018 Procedures for Tracking of Staff and Patients were deficient as the facility lacked a policy to track on-duty staff and sheltered residents during emergencies or relocations.
E025 Arrangement with Other Facilities was deficient as the facility failed to maintain written agreements for transfer of residents to sister facilities during emergencies.
E026 Roles Under a Waiver Declared by Secretary were deficient as the facility lacked policies identifying its role under a waiver for care at an alternate site during emergencies.
K271 Discharge from Exits was deficient due to unsafe walking surfaces and a driveway with large potholes obstructing safe evacuation.
K300 Protection - Other was deficient as the facility failed to maintain attic space free from combustible materials.
K345 Fire Alarm System - Testing and Maintenance was deficient as the fire alarm system did not function properly and lacked proper certification documentation.
K353 Sprinkler System - Maintenance and Testing was deficient due to failure to maintain sprinkler heads and escutcheon plates free from paint, rust, and debris.
K354 Sprinkler System - Out of Service was deficient as the facility failed to ensure complete policy for fire watch when sprinkler system was out of service for more than four hours.
K355 Portable Fire Extinguishers were deficient as the facility failed to inspect all extinguishers monthly and maintain proper records.
K711 Evacuation and Relocation Plan was deficient as staff lacked training on fire safety and grease fire extinguishing procedures.
K921 Electrical Equipment - Testing and Maintenance was deficient due to incomplete electrical inspections and failure to maintain compliance with National Electrical Code.
Report Facts
Facility capacity: 69
Resident census: 62
Estimated repair cost: 70000
Fire extinguisher last checked date: Feb 15, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in multiple findings related to fire safety inspections, maintenance, and training | |
| Administrator | Named in findings related to fire safety training and policy updates | |
| Cook C | Named in fire safety training deficiency related to grease fire handling |
Inspection Report
Plan of Correction
Census: 59
Deficiencies: 2
Date: Dec 3, 2021
Visit Reason
The inspection was conducted to investigate compliance with transfer and discharge requirements following a complaint or incident involving the discharge of a resident who touched a staff person in a sexual manner and was not allowed to return.
Findings
The facility failed to ensure proper emergency discharge notice was issued to one resident, did not assist in placement after discharge, and did not follow transfer and discharge policies consistent with federal and state regulations. The resident census was 59 at the time of inspection.
Deficiencies (2)
F622 Transfer and Discharge Requirements: The facility did not issue a proper emergency discharge notice to a resident who was discharged after touching a staff person in a sexual manner and was not allowed to return. The facility also failed to assist the resident in finding appropriate placement after discharge.
A8018 Emergency Discharges: The facility did not submit a written notice of discharge to the resident or legally authorized representative as required in emergency discharge situations.
Report Facts
Resident census: 59
Inspection Report
Routine
Census: 58
Deficiencies: 4
Date: Jul 20, 2021
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted to assess compliance with related regulations.
Findings
The facility was found to be in compliance with COVID-19 emergency preparedness requirements but failed to meet requirements for food temperature and environmental cleanliness. Multiple deficiencies were cited related to serving food at safe temperatures and maintaining a clean, odor-free environment.
Deficiencies (4)
F804: The facility failed to serve hot foods at an appetizing temperature, affecting three residents. The facility lacked a policy on food temperatures.
F921: The facility failed to provide a safe, functional, sanitary, and comfortable environment. Observations included damp bath blankets, strong odors, sticky floors, and unclean bathrooms.
A5005: The regulation requiring hot food to be served hot and cold food to be served cold was not met, referencing F804.
A6012: Floors and floor coverings in food-preparation and other areas were not properly cleaned or maintained, referencing F921.
Report Facts
Facility census: 56
Facility census: 58
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Clark Unha | Administrator | Signed the report and plan of correction |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 7
Date: Mar 10, 2021
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment at the facility.
Complaint Details
The visit was complaint-related due to allegations of abuse, neglect, exploitation, or mistreatment. The facility was found not to have thoroughly investigated and reported an injury of unknown origin to Resident #19. The complaint was substantiated based on interviews and record review.
Findings
The facility failed to respect residents' dignity and right to personal property, and did not properly investigate and report an injury of unknown origin to a resident. Additionally, the facility failed to provide adequate assistance with activities of daily living for dependent residents.
Deficiencies (7)
F557 Respect, Dignity/Right to have Personal Property. The facility failed to ensure residents' dignity by not assuring residents' sides, abdomens, buttocks, and briefs remained covered in public areas and did not honor residents' right to retain personal possessions such as furnishings and clothing. The facility census was 59.
F610 Investigate/Prevent/Correct Alleged Violation. The facility failed to maintain assessment documentation and timely report an injury of unknown origin for Resident #19, and did not thoroughly investigate allegations of abuse, neglect, or mistreatment.
F677 ADL Care Provided for Dependent Residents. The facility failed to provide necessary assistance or oversight with showers and personal hygiene for three residents, including Residents #3, #5, and #12. The facility census was 59.
A4074 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 Class II deficiencies.
A8023 Develop/Implement A/N Policies. The facility failed to develop and implement written policies and procedures to prohibit mistreatment, neglect, and abuse of residents and to report such incidents to the department and other authorities.
A8030 Dignity/Privacy. Each resident shall be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and care of personal needs. This regulation was not met as evidenced by Class II deficiencies.
A8037 Personal Clothing/Possessions. Each resident shall be permitted to retain and use personal clothing and possessions as space permits. This regulation was not met as evidenced by Class II deficiencies.
Report Facts
Facility census: 59
Days resident waited for personal belongings: 108
Days without documented showers: 38
Days without documented showers: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kyrie Clarke | Administrator | Signed the plan of correction |
| Director of Nurses | Interviewed regarding clothing and bruising issues | |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed about resident care and bruising |
| CNA C | Certified Nursing Assistant | Interviewed about resident clothing and care |
| CNA F | Certified Nursing Assistant | Interviewed about resident bruising and care |
| CNA G | Certified Nursing Assistant | Interviewed about resident bruising and care |
| RN A | Registered Nurse | Interviewed about bruising and incident reporting |
Inspection Report
Plan of Correction
Census: 55
Deficiencies: 3
Date: Oct 1, 2020
Visit Reason
The inspection was conducted as a COVID-19 focused emergency preparedness survey and included review of compliance with reporting requirements and infection control procedures.
Findings
The facility failed to inform residents and their responsible parties of positive COVID-19 test results in a timely manner and failed to report positive PCR test results within 24 hours. The facility was found out of compliance with reporting requirements for communicable diseases and notification of responsible parties.
Deficiencies (3)
F885 COVID-19 reporting. The facility failed to inform two residents' responsible parties after positive COVID-19 tests and did not notify responsible parties timely as required.
A4085 Infection Control/Communicable Disease. The facility failed to report positive PCR test results for residents and staff within 24 hours as required by state regulations.
A4087 Notify Responsible Party-Change in Condition. The facility failed to notify responsible parties of residents' COVID-19 positive status in a timely manner.
Report Facts
Facility census: 55
Residents testing positive for COVID-19: 25
Staff testing positive for COVID-19: 46
Residents testing positive for COVID-19: 11
Residents testing positive for COVID-19: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Moore | Administrator | Signed deficiency statements and plan of correction |
Inspection Report
Routine
Deficiencies: 0
Date: Aug 25, 2020
Visit Reason
A COVID-19 focused infection control survey and a COVID-19 focused emergency preparedness survey were conducted from 08/20/2020 to 08/25/2020 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
Abbreviated Survey
Deficiencies: 0
Date: May 26, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted from May 21 to May 26, 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: 62
Deficiencies: 9
Date: Aug 22, 2019
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for nursing home facility St Joseph Chateau.
Findings
The facility was found deficient in multiple areas including residents' rights, safe environment, notice requirements before transfer/discharge, professional standards of care, pressure sore prevention, infection control, and accident prevention. Several residents were affected by these deficiencies, and the facility failed to follow policies and procedures in these areas.
Deficiencies (9)
F550 Resident Rights/Exercise of Rights: Facility failed to assure staff treated residents with dignity and responded timely to call lights, affecting multiple residents. Flies were present in dining and resident areas.
F584 Safe/Clean/Comfortable/Homelike Environment: Facility failed to protect residents' personal belongings from loss or theft, affecting two residents.
F623 Notice Requirements Before Transfer/Discharge: Facility failed to provide written notice of transfer or discharge to residents or their representatives for two residents.
F625 Notice of Bed Hold Policy Before/Upon Transfer: Facility failed to inform residents and their representatives of bed hold policy at time of transfer for two residents.
F658 Services Provided Meet Professional Standards: Facility failed to ensure staff followed physician orders for insulin administration and lab orders for multiple residents.
F677 ADL Care Provided for Dependent Residents: Facility failed to provide complete perineal care and maintain good grooming and hygiene for three residents.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: Facility failed to complete weekly skin assessments and identify/treat two new Stage II pressure ulcers for one resident.
F689 Free of Accident Hazards/Supervision/Devices: Facility failed to ensure proper techniques to reduce accident hazards during mechanical lift transfers for one resident.
F880 Infection Prevention & Control: Facility failed to establish and maintain an infection prevention and control program to prevent communicable diseases and infections.
Report Facts
Facility census: 62
Sampled residents: 17
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding call light response times, flies issue, and care policies |
| Licensed Practical Nurse A | Licensed Practical Nurse | Observed administering insulin and reporting blood sugar levels |
| Certified Nurse Aide A | Certified Nurse Aide | Observed assisting residents with transfers and hygiene |
| Certified Nurse Aide B | Certified Nurse Aide | Observed assisting residents with transfers and hygiene |
| Administrator | Administrator | Interviewed regarding transfer/discharge notices and facility policies |
Inspection Report
Life Safety
Census: 54
Capacity: 69
Deficiencies: 7
Date: Aug 22, 2019
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 regulations.
Findings
The facility failed to maintain proper delayed egress locking arrangements, lacked proper signage on exit doors, had fire extinguishers mounted at incorrect heights, and had issues with fire alarm system faults and fire drills. These deficiencies could delay emergency evacuation and staff response.
Deficiencies (7)
K222 Egress Doors: The facility failed to maintain all exit egress doors in accordance with NFPA 101. Staff did not display proper signage on the front door to indicate it was a delayed egress door, causing potential confusion during emergencies.
K355 Portable Fire Extinguishers: Fire extinguishers were mounted higher than the required maximum height of 5 feet, which could delay staff access during emergencies.
K712 Fire Drills: The facility failed to assure staff took immediate action when the fire alarm indicated a trouble signal, potentially delaying emergency services and staff response.
A2012 Fire Extinguishers-Minimum per Floor: The facility did not provide a minimum of one fire extinguisher per floor within 75 feet travel distance as required.
A2024 Fire Alarm System-Correct Faults: The facility failed to correct faults in the fire alarm system as evidenced by trouble signals and dead batteries.
A2037 Exit Requirements: The facility did not meet exit requirements for unobstructed exits and fire-rated separation.
A2065 Fire Safety Training Requirements: The facility failed to meet fire safety training requirements including prevention, detection, evacuation, and alarm response.
Report Facts
Bed capacity: 69
Resident census: 54
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 5
Date: Nov 30, 2018
Visit Reason
The inspection was an annual survey conducted to assess compliance with federal regulations for nursing home care, including abuse/neglect policies, comprehensive care plans, behavioral health services, medication error rates, and infection control.
Findings
The facility was found deficient in developing and implementing abuse/neglect policies, comprehensive person-centered care plans, behavioral health services, maintaining medication error rates below 5%, and infection prevention and control. Several residents' care plans lacked updates or necessary interventions, and the facility failed to ensure proper background checks and psychiatric services.
Deficiencies (5)
F607: The facility failed to develop and implement written abuse/neglect policies, including required background checks for employees. The facility census was 65.
F656: The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for residents, affecting three of 17 sampled residents. The facility census was 65.
F740: The facility failed to provide necessary behavioral health services and psychiatric treatment for residents, including failure to arrange psychiatrist appointments and address mental health needs.
F759: The facility failed to maintain medication error rates below 5%, with an 8% error rate affecting two residents. Medication administration errors were observed.
F880: The facility failed to establish and maintain an infection prevention and control program, affecting three of 17 sampled residents. Proper procedures for cleaning and dressing changes were not followed.
Report Facts
Facility census: 65
Sampled residents affected: 3
Medication error rate: 8
Residents affected by medication errors: 2
Residents affected by infection control deficiencies: 3
Inspection Report
Life Safety
Deficiencies: 0
Date: Nov 30, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and Emergency Preparedness requirements for the facility.
Findings
No deficiencies were found in the Emergency Preparedness portion or the Life Safety Code compliance. No state licensure deficiencies were cited during the inspection.
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