Advanced Care of St. Joseph

Inspectors wroteBased on observation, interview and record review, the facility failed to protect two resident's right to choice when the facility did not provide written notification of room changes to two residents (Residents #1 and #2) or their family members. This affected two residents of five residents sampled. The facility's census was 155. Review of facility policy Resident Rights, revised 9/1/24, showed:- The resident had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed;- The resident had the right to refuse to transfer to another room in the facility if the purpose of the transfer was solely for the convenience of the staff;- The resident had the right to make choices about aspects of his or her life in the facility that are significant to the resident;1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided catheter care (a sterile tube inserted into the urinary bladder to drain urine) in a manner to prevent urinary tract infection (UTI) or the possibility of a UTI, when staff cleaned the catheter tubing towards rather than away from the resident's insertion site and when staff failed to empty the urinary collection bag when full. This affected one of the six sampled residents (Resident #39). The facility census was 149. Review of the facility policy titled Catheter Care, dated 9/1/21, showed: - It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use;- Catheter care will be performed every shift and as needed by nursing personnel; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of the 18 sampled residents (Resident #88) when staff failed to administer the resident's scheduled seizure medication as ordered, per facility documentation the resident had unfortunately ran out of his/her seizure medication which likely resulted in a breakthrough seizure. The facility census was 144. Review of the facilities resident right policy dated. 9/1/2021., showed:Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. 1. Review of resident #88's Face Sheet record, showed: -The resident was admitted to the facility on [DATE].-Resident is cognitively intact. -Diagnoses includes: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident dignity when staff failed to remove unwanted facial hair for two residents (Residents #21 and Resident # 58), failed to provide timely incontinence cares for three residents (Residents #5, #58, and #145), and failed to create a safe environment causing one resident to feel retaliated against or intimidated (Resident #83). This affected 11 out of the 18 sampled residents. The facility census was 144. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to act promptly upon the grievances of the resident council members concerning issues of resident care and life in the facility and failed to communicate back with the resident council regarding the resident's concerns. This had the potential to affect all the residents who lived in the facility. The facility census was 144. Review of the facility's policy, Resident Council Meetings, dated 9/1/21 showed;- This facility supports the rights of residents to organize and participate in resident groups, including a Resident Council. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents knew how to file a grievance and failed to ensure residents' grievances were fully addressed, steps taken to resolve the grievances, notification of the residents of the results of the grievance and follow up with the residents to ensure the issues were resolved. This had the potential to affect any resident who resided in the facility. The facility census was 144. Review of the facility's policy, Resident Council Meetings, dated 9/1/21 showed;- This facility supports the rights of residents to organize and participate in resident groups, including a Resident Council. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to schedule care plan meetings for two of the 29 sampled residents, (Resident #90, #121) and failed to ensure staff developed and updated a care plan consistent with the resident's specific conditions and needs which affected Resident #129. The facility census was 144. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received the necessary services to maintain good personal hygiene when staff did not provide showers in a timely manner for three of the 29 sampled residents, (Resident #10, #12 and #203). The facility census was 144. Review of facility policy Resident Showers, dated 9/1/21, showed:- Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety;- Partial baths may be given between regular shower schedules as per facility policy; Review of facility policy Resident Rights, revised 9/1/22, showed the resident has the right to receive services in the facility with reasonable accommodation of resident needs and preferences; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper respiratory care when staff failed to document the date when oxygen tubing was cleaned and failed to properly store oxygen accessories at the bedside for three residents (Residents #71, #28, and #43) resulting in possible exposure to bacteria during oxygen usage. This affected three of 18 sampled residents. The facility census was 144. Review of facility oxygen administration, infection control measures policy, revised on 07/03/2024, showed infection control measures to include: - Follow manufacturer recommendations for the frequency of cleaning equipment filters- Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated- Change humidifier bottle when empty, weekly or per facility policy, or as recommended by the manufacturer. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure staff administered medications with an error rate of less than five percent (5%). Staff made eight errors out of 37 opportunities for error, which resulted in an error rate of 24.32%. This affected four of the 29 sampled residents, (Resident #64, #21, #100, #34) and three unknown residents who had their medications preset. The facility census was 144. Review of the facility's policy for Medication Administration, revised 9/1/22 showed: Medications are administered by licensed nurses, or other staff who are legally authorized to do in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; Wash hands prior to administering medication per facility protocol and product; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff did not make significant medication errors when staff failed to prime the insulin pens with two units prior to administration which affected three of the 29 sampled residents, (Resident #64, #21, and #100). The facility census was 144. Review of the facility's policy for Medication Administration, revised 9/1/22 showed:-Review Medication Administration Record (MAR) to identify medication to be administered;-Administer medication as ordered in accordance with manufacturer specifications. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure there were no loose pills in the medication carts and failed to date opened vials of Lorazepam (used to treat anxiety) for four of the 29 sampled residents, (Resident #25, #76, #52 and #9). Additionally, staff failed to ensure medication was not left at the bedside for Resident #11. The facility census was 144. Review of facility policy Medication Storage, revised 9/1/22, showed:- It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Unused medications: [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that the food served to the residents was appealing and appetizing when residents at a group meeting and one Resident (#32) out of 18 sampled residents verbalized concerns over the quality of the food. The facility census was 144. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to discard expired leftovers in the refrigerator, failed to wear beard nets while working in the kitchen, and failed to maintain proper standards of cleanliness in the walk-in refrigerator. This had the potential to impact all residents by placing them at risk for a food borne illness. The facility census was 144. Review of facility policy Dietary Employee Personal Hygiene, revised 9/1/22, showed all dietary staff must wear hair restraints (e.g. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents' medical records were complete and accurate when staff failed to document and screen a one resident (Resident #20) accurately during pain assessments and failed to properly document showers for two residents (Resident #12 and #121). This affected three out of 29 residents sampled. The census was 144. Review of facility policy Maintenance of Clinical Records, revised 6/2/22, showed:- The facility will maintain clinical records for each resident in accordance with acceptable standards of practice that reflects the current plan of care and services provided as well as in a manageable size for use by the care providers;- The facility must maintain medical records on each resident that are: complete, accurately documented, and systematically organized;- The clinical record will contain: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff provided care in a manner to prevent infection or the possibility of infection when staff did not use proper hand hygiene when obtaining blood sugars and the administration of insulin, failed to clean the port of the insulin pen prior to attaching the needle and failed to clean the glucometer between three of the 29 sampled residents, (Resident #64, #21, and #100) . The facility census was 144. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality of care when, facility staff documented they had administered prescription eye drops to one resident (Resident #95) and showed the prescription eye drops were opened and dated on 05/02/25, the bottle was still full on 07/02/25 at 04:35 A.M. indicating several doses of the eye medication were missed, but documented. This affected one resident out of the sampled 18 residents. The facility census was 144. Review of facility administration of eye drops policy, revised on 09/24/24., showed: Label new bottle with date opened and follow facility policy or manufacturers instruction for when to discard and replace. Record administration of medication as ordered by the physician.1. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff provided catheter (a sterile tube inserted into the urinary bladder to drain urine) care in a manner to prevent urinary tract infection (UTI) or the possibility of a UTI, which affected one of the 29 sampled residents, (Resident #9). The facility census was 144. Review of the facility's policy for Catheter Care, revised 5/24/24 showed: -It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use;- Catheter care will be performed every shift and as needed by nursing personnel;- Gently separate the skin folds to expose the urinary meatus. Wipe from front to back with a clean cloth. Use a new part of the cloth or different cloth for each side. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff provided adequate pain control for one of 29 sampled residents (Resident #20). The facility census was 144. Review of facility policy Pain Management, revised 4/23/25, showed:- The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goal and preferences;- The facility will recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated;- Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences;- Facility staff will observe for nonverbal indicators which may indicate the presence of [...]

Inspectors wroteBased on interviews and record review the facility failed to complete neurological assessment's for one resident (Resident #1), after the resident reported to Registered Nurse (RN) A on he/she had fallen the night prior and someone picked him/her off the floor. The resident was noted to have bruise to his/her torso and increased confusion. RN A did not initiate neurological assessment's. Additionally, the facility Certified Nurses Aide (CNA) A failed to notify the nurse immediately when he/she found the resident on the floor during the night of 12/4/24. CNA A and CNA B assisted the resident off the floor and back to bed. The facility census was 139. Review of the fall policy dated 2020 showed: - The staff were supposed to assess the resident after a fall; - The staff were supposed to complete a post-fall assessment. Review of the head injury policy dated 9/1/21 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and treatment in accordance with professional standards of practice when licensed nursing staff failed to ensure that physician's orders were carried out for three of five sampled residents sampled when medications were not administered timely (Resident #1, #4, and #5) and when blanks were left in the medication administration record (MAR) and treatment administration record (TAR) for two residents, (Resident #4 and #5). The facility census was 128. Review of facility policy, Medical provider orders, revised 4/7/22, showed: -Following of Medication and/or Treatment Orders: -Staff should follow all valid medical provider orders timely unless there is an emergency which would temporarily delay the implementation of the order. Review of the facility policy, Medication Administration, revised 9/1/22, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish and maintain a system that assured a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf when the facility had no available personal funds statements for review for six of twelve months reviewed from June 2023 to November 2023 and when the facility's cash on hand did not balance with receipts. The facility census was 128. The facility did not provide a policy. 1. Observation on 7/2/24 at 3:35 P.M. showed the business office manager (BOM) counting cash on hand for resident petty cash. The BOM showed a balance of $1340.79 in petty cash before the receipts were deducted. Observation showed $818.58 cash on hand and a receipt balance of $463.12 providing a total of $1281.70. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure dry foods were stored in sealed containers for food freshness and protection from pest for all 128 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, document review, and facility policy review, the facility failed to maintain an effective pest control program for five of six halls (100, 200, 300, 400, and 600), two nurses' stations, shower rooms, therapy room and the kitchen which includes the dish room area.

Inspectors wroteBased on observation, interview, record review, facility policy review and review of manufacturer's instructions, the facility failed to provide respiratory care in accordance with professional standards for four (Residents (R) 62, R24, R45, and R53) of four residents reviewed for respiratory care out of a total sample of 33 residents. Respiratory equipment, such as bipap (bilevel positive airway pressure), cipap (continuous positive airway pressure), and nebulizer masks and chambers, were not stored in a sanitary manner; oxygen, cipap, bipap, and nebulizer units were dusty with grim; and there was no process for cleaning and maintaining cipap/bipap units. R62 did not have a physician order for cipap, R24's oxygen rate was not per the physician's order, and R45 and R53 had liquid in their nebulizer chambers. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to implement an appropriate infection control program for eight of 33 residents (Resident) R)6, R24, R34, R47, R61, R79, R94, and R115 resulting in psychosocial harm to R61. Specifically, the facility failed to 1. follow their policy for isolation during treatment for scabies for R61; 2. follow enhanced barrier precautions for six residents R6, R24, R94, R115, R34 and R47; and 3. follow appropriate hand hygiene during meal service for R79.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of three residents (Resident (R) 37) and their resident representatives (RR) in the sample of thirty-three reviewed for facility initiated emergent hospital transfer, was provided with a written transfer notice that contained all the required information. This failure has the potential to affect the resident and their RRs by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review and interview, the facility failed to provide one of three residents, or their resident representative (RR) reviewed for hospitalization (Resident (R) 37) with written notification of the bed hold policy prior to transfer to the hospital. This created a potential for the resident to experience distress or confusion related to readmission to the facility due to the facility-initiated discharge.

Inspectors wroteBased on record review, interviews, policy review and review of the Resident Assessment instrument (RAI) manual, the facility failed to accurately code the Minimum Data Set (MDS) for one of 33 residents (Resident (R) 37) reviewed for MDS accuracy. Failure to accurately code the MDS could result in the resident not receiving care and services.

Inspectors wroteBased on record review, and staff interviews, the facility failed to ensure a Level 1 Pre-admission Screening and Resident Review (PASARR) was completed for two of three residents (Resident (R) 22 and R60) reviewed for PASARR.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan for one of 33 residents (Resident) R) 61) in the sample creating the potential for R61 to be at risk for unmet needs due to a skin condition.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to provide documentation of behavior monitoring for the continued use of an antipsychotic medication for one of five residents (Resident (R)121) reviewed for unnecessary medications. Failure to provide quantitative data regarding target behavior reduction/management has the potential to affect the resident receiving the lowest dose possible of a psychoactive medication.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure for one Resident (R)26) of one resident in the sample of 33 residents. The nursing staff failed to follow the facility's policy to secure 17 insulin pens in the medication cart or medication room. This practice could potentially affect the safe administration of residents' medications.

Inspectors wroteBased on observations and interview, the facility failed to ensure the daily nurse staff posting was available for all residents, families, and visitors. This failure had the potential to inaccurately inform any resident, family member, or visitor of the facility of the available nursing staff caring for residents.

Inspectors wroteBased on interview and record review, the facility failed to operationalize the Illegal Drug Use policy to ensure the environment for two sampled residents (Resident #1 and Resident #2) were free from hazards when staff repeatedly found illegal drugs and/or drug paraphernalia in a shared room occupied by two residents, Resident #1 and Resident #2. The facility census was 106. Review of the facility's policy Resident Rights revised, [DATE], included the resident has the right to safe environment including receiving supports for daily living safely. Review of the facility's policy Illegal Drug Use dated, [DATE], included: -The facility is an illegal drug-free facility; -The purpose of this policy is to ensure the safety of all employees, residents, family members, visitors and any others that enter the facility. [...]

Inspectors wrotePlease refer to Event ID MW6512 for this deficiency content. Based on record review and interview, the facility failed to thoroughly investigate an allegation of sexual abuse when one resident (Resident #3) reported he/she was sexually abused by his/her roommate (Resident #4). The facility failed to provide evidence the alleged violations were thoroughly investigated and to follow facility policy when failed to provide documentation that all staff working were interviewed, failed to interview facility residents, and failed to provide complete and thorough documentation of the investigation. The facility census was 123. Review of facility policy, Abuse, Neglect, and Exploitation, revised 8/22/22, showed: [...]

Inspectors wrotePlease refer to Event ID MW6512 for this deficiency content. Based on interview and record review, the facility failed to provide care and treatment in accordance with professional standards of practice when licensed nursing staff failed to ensure that physician's orders were carried out for two of four residents (Resident #1 and #2) when blanks were left in the medication administration record (MAR) and treatment administration record (TAR) and when staff left medication at Resident #1's bedside to self administer. This affected two of four sampled residents. The facility census was 123. Review of the facility policy, Medication Administration, revised 9/1/22, showed: [...]

Inspectors wroteBased on observation, record review, and interview the facility failed to prepare and serve food in accordance with professional standards for food service safety when staff failed to keep a clean kitchen and dining room, failed to label and date food when it was opened, failed to completed temperature checks on fridge/freezers, failed to store food off the floor, failed to ensure proper sanitation of food preparation services, failed to use clean serving bowls, failed to keep trash cans covered, failed to use proper hand washing techniques during food preparation and meal service, and failed to have cleaning routines in kitchen. This had the potential to impact all residents in the facility. The facility census was 119. 1. Review of facility policy, food safety requirements, dated 11/2017, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided showers to dependent residents when staff did not provide at least two showers a week to five residents (Resident #1, #2, #3, #4, #5) of five residents sampled. The facility census was 119. Review of facility's resident shower policy, dated 9/1/21, showed: -It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues as per current standards of practice. -Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. -Partial baths may be given between regular shower schedules as per facility policy. Review of facility policy, bathing a resident, dated 9/1/21, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications in a locked storage area to ensure medications were inaccessible to unauthorized staff and residents, when the medication cart was left unlocked and unattended. The facility census was 119 Review of policy, medication storage, dated 9/1/21, showed: -It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. -All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms. -Only authorized personnel will have access to the keys to locked compartments. [...]

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of sexual abuse when one resident (Resident #3) reported he/she was sexually abused by his/her roommate (Resident #4). The facility failed to provide evidence the alleged violations were thoroughly investigated and to follow facility policy when failed to provide documentation that all staff working were interviewed, failed to interview facility residents, and failed to provide complete and thorough documentation of the investigation. The facility census was 123. Review of facility policy, Abuse, Neglect, and Exploitation, revised 8/22/22, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and treatment in accordance with professional standards of practice when licensed nursing staff failed to ensure that physician's orders were carried out for two of four residents (Resident #1 and #2) when blanks were left in the medication administration record (MAR) and treatment administration record (TAR) and when staff left medication at Resident #1's bedside to self administer. This affected two of four sampled residents. The facility census was 123. Review of the facility policy, Medication Administration, revised 9/1/22, showed: -Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection; [...]

Inspectors wroteBased on interview and record review, the facility staff failed to monitor, assess, and implement interventions to prevent an elopement of one resident (Resident #1) when staff allowed the resident to elope from facility on 12/5/23 which resulted in resident becoming intoxicated and taken to emergency room. This affected one of three sampled residents. The facility census was 116. Review of facility policy, elopements and wandering residents, dated 9/1/22, showed: -Facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. -Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge. This affected seven additionally sampled residents (Residents #245, #246, #247, #248, #249, #250, and #251) Facility census was 92. 1. Review of the facility Refund Process policy, dated 7/15/21, showed: - Refunds are requested to process money that was overpaid to the facility for resident services provided. Refunds may be made payable to the responsible party, resident, insurance company, State, or medical providers. Potential refund amounts can be identified on the Accounts Receivable (AR) aging report for the facility. - Refunds may be requested by the center or Corporate Business Office (CBO). The Business Office Manager (BOM) will forward completed refund request with all required documentation to AR. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to prepare and serve food in accordance with professional standards for food service safety, and failed to ensure they stored food properly. The facility census was 92. Review of the facility's policy, revised 4/29/18 Food Storage: Cold Food in part said: - All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. 1. All food items will be stored 6 inches above the floor and 18 inches below the sprinkler unit. 2. All perishable foods will be maintained at a temperature of 41 degrees farenheit or below, except during necessary periods of preparation and service. 3. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. 1. [...]