Inspection Reports for
St Joseph Chateau
811 NORTH 9TH ST, SAINT JOSEPH, MO, 64501-1651
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
142% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
99% occupied
Based on a September 2025 inspection.
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
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
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
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: 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
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
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
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
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
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 |
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