Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265762

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOSEPH SENIOR LIVING

STREET ADDRESS, CITY, STATE, ZIP

1317 NORTH 36TH STREET
SAINT JOSEPH, MO 64506

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0640

Level of harm – Potential for minimal harm

Residents Affected – Some

Encode each resident’s assessment data and transmit these data to the State within 7
days of assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure staff electronically
transmitted resident assessments, using the Minimum Data Set (MDS-a federally mandated
assessment instrument completed by facility staff) to CMS (Centers for Medicare and
Medicaid Services) within 14 days after the facility completed quarterly assessments for
five residents (Residents #1, #2, #3 and #24) and did not transmit a discharge subset
within 14 days for two residents (Resident #4 and #24).
1. Resident #1’s CMS MDS entries showed:
-Most recent comprehensive MDS assessment (admission or significant change it condition
required to be completed annually) was an annual MDS, dated [DATE];
-Most recent quarterly MDS assessment (required to be completed every three months), dated
8/3/18;
-No transmission of a quarterly MDS assessment, which was due 11/3/18;
-Currently resided in the facility.
Review of the resident’s MatrixCare (an electronic health record computer program) MDS
status report, dated 11/1/18-2/11/19, showed the 11/3/18 quarterly MDS production was
accepted.
2. Resident #2’s CMS MDS entries showed:
-Most recent comprehensive MDS assessment was a significant change in condition MDS, dated
[DATE];
-Most recent quarterly MDS assessment, dated 8/3/18;
-No transmission of a quarterly MDS assessment, which was due 11/3/18;
-Currently resided in the facility.
Review of the resident’s MatrixCare MDS status report, dated 11/1/18-2/28/19, showed the
11/3/18 quarterly MDS production was accepted.
3. Resident #3’s CMS MDS entries showed:
-Most recent comprehensive MDS assessment was an annual MDS, dated [DATE];
-Most recent quarterly MDS assessment, dated 9/7/18;
-No transmission of an annual MDS assessment, which was due 12/7/18;
-Currently resided in the facility.
Review of the resident’s MatrixCare MDS status report, dated 10/1/18-2/11/19, showed an
annual MDS, dated [DATE], was validated, not accepted.
During an interview on 2/11/19 at 3:35 P.M., the administrator said:
-The facility just hired a new MDS coordinator, but he/she had not technically started.
-The administrator thought he/she had submitted the resident’s annual MDS and that it was
accepted, but it was not.
4. Resident #4’s CMS MDS entries showed:
-An admission MDS, dated [DATE];
-No quarterly MDS assessment, which was due 12/12/18;
-Did not indicate whether resident currently resided in the facility.
Review of the resident’s MatrixCare MDS status report, dated 8/28/18-2/11/18, showed:
-An entry subset, dated 9/5/18, which showed production accepted with warning;
-A 5-day PPS (Prospective Payment System) subset, dated 9/12/18, which showed completed;
-An admission MDS, dated [DATE], which showed production accepted;
-A 14-day PPS subset, dated 9/19/18, which showed completed;
-A discharge with return not anticipated subset, dated 11/1/18, which showed production
accepted.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265762

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOSEPH SENIOR LIVING

STREET ADDRESS, CITY, STATE, ZIP

1317 NORTH 36TH STREET
SAINT JOSEPH, MO 64506

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0640

Level of harm – Potential for minimal harm

Residents Affected – Some

(continued… from page 1)
During an interview on 2/11/19 at 3:35 P.M., the administrator said that the resident was
discharged on [DATE], so there should be a discharge subset transmission.
5. Resident #24’s CMS MDS entries showed:
-A quarterly MDS, dated [DATE];
-A discharge subset with return anticipated, dated 9/26/18;
-A reentry subset, dated 9/29/18;
-A 5-day PPS subset, dated 10/5/18;
-A 14-day PPS, dated 10/12/18;
-A return entry, dated 10/23/18 (no discharge subset between 10/12/18 and 10/23/18);
-No quarterly MDS, due 11/3/18.
Review of the facility’s MatrixCare (an electronic health record computer program) Report
for 8/1/18-2/11/19, showed:
-A quarterly MDS, dated [DATE], which showed production accepted;
-A discharge subset with return anticipated, dated 9/26/18, which showed production
accepted;
-An entry subset, dated 9/29/18, which showed production accepted;
-A 5-day PPS, dated 10/5/18, which showed production accepted;
-A 14-day PPS, dated 10/12/818, which showed production accepted;
-A discharge with return anticipated, dated 10/18/18, which showed production accepted;
-An entry subset, dated 10/23/18, which showed production accepted;
-A quarterly MDS, dated [DATE], which showed production accepted.
During an interview on 2/11/19 at 3:36 P.M., the administrator said:
-Their computer system showed the MDS’s for Residents #1, #2, and #4 to be current and all
submitted and accepted.
-Their computer system also showed Resident #4’s discharge subset was completed and
accepted.
-The only MDS not current and accepted was for Resident #3, which was completed but not
transmitted.
-He/she did not know why the CMS system did not show them as up-to-date.
During a phone interview on 2/13/19, at 3:05 P.M., the MDS state automation coordinator
said:
-None of the missing MDS’s for Residents #1, #2, #3, #4 and #24 were transmitted through
the CMS system.
-It can be deceiving if MDS’s are only transmitted through a facility’s electronic
healthcare system, such as Matrix, as it might show it was accepted, but was actually not
accepted into the CMS system.
-Facility’s need to pull the final validation of transmitted MDS’s from CMS CASPER
(Certification and Survey Provider Enhanced Reports).

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed acceptable standards of practice when staff correctly transcribed a medication
order from one electronic physician order [REDACTED].#5). The facility census was 58.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265762

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOSEPH SENIOR LIVING

STREET ADDRESS, CITY, STATE, ZIP

1317 NORTH 36TH STREET
SAINT JOSEPH, MO 64506

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
Review of the facility’s policy related to medication administration, revised (MONTH)
2012, showed:
-Medications shall be administered in a safe and timely manner, and as prescribed.
-Medications must be administered in accordance with the orders.
-If a dose is believed to be inappropriate or excessive for a resident, the person
preparing or administering the medication shall contact the resident’s attending physician
or the facility’s medical director to discuss the concerns.
-The individual administering the medication must check the label to verify the right
resident, right medication, right dosage, right time and right route of administration
before giving the medication.
1. Review of Resident #5’s MatrixCare (a specific electronic health record system) (MONTH)
2019 e-POS showed an order, dated 6/21/16, for [MEDICATION NAME] ([MEDICATION
NAME]-[MEDICATION NAME], a medication used to treat body odors) 0.6-3 milligrams (mg),
take one tablet with meals AM (morning), midday and PM (evening) for malodorous urine.
Review of the resident’s MatrixCare (MONTH) 2019 e-MAR showed the resident received the
Cholorphyll as prescribed 1/1/19-1/16/19.
Review of the resident’s AHT (a specific electronic health record system) (MONTH) 2019
e-POS showed an order, dated 1/7/19, for [MEDICATION NAME] 20 mg, take three times a day
with meals for malodorous urine.
Review of the resident’s (MONTH) 2019 AHT e-MAR showed the resident received [MEDICATION
NAME] 20 mg three times a day with meals 1/17/19-1/31/19.
Review of the resident’s (MONTH) 2019 AHT e-POS showed an order, dated 1/7/19, for
[MEDICATION NAME] 20 mg three times a day.
Observation and interview on 2/8/19 at 12:16 P.M., showed Certified Medication Technician
(CMT) did and said:
-Checked the e-MAR;
-Removed the resident’s bottle of [MEDICATION NAME], with a label that indicated it
contained [MEDICATION NAME]-[MEDICATION NAME] 0.6 mg-3 mg per tablet, from the medication
cart and placed one tablet in a medication cup and prepared to administer the medication
to the resident;
-When questioned about the dose, he/she said he/she had not previously noticed there was a
different dose on the medication bottle compared to the dose on the e-MAR.
-He/she reported the issue to the assistant director of nurses (ADON).
Review of the resident’s (MONTH) 2019 AHT e-MAR showed staff documented they administered
[MEDICATION NAME] 20 mg three times a day 2/1/19 through the noon dose on 2/8/19.
During an interview on 2/8/19 at 12:33 P.M., the ADON said:
-He/she spoke with the resident’s physician who clarified that the [MEDICATION NAME] dose
should be 3 mg.
-The original order for the medication was for 3 mg, but staff incorrectly entered the
order into the new computer system when they changed systems.
During a phone interview on 2/11/19 at 3:47 P.M., the Director of Nurses (DON) said:
-Three nurses entered and checked orders when the facility changed computer systems and
he/she was still reviewing orders for accuracy.
-Physicians should also look at physician orders [REDACTED].
-He/she did not catch the incorrect dose entered into the new e-POS/e-MAR system for the
resident’s [MEDICATION NAME].
-Staff should check the medication container dose with the dose on the e-MAR and clarify
with the resident’s physician if they do not match.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265762

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOSEPH SENIOR LIVING

STREET ADDRESS, CITY, STATE, ZIP

1317 NORTH 36TH STREET
SAINT JOSEPH, MO 64506

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
promptly identified a pressure ulcer and initiated wound care for one out of 15 sampled
residents (Resident #17). The facility census was 58.
Review of the facility’s policy related to pressure ulcers, revised (MONTH) 2014, showed:
-The nursing staff and attending physician will assess and document an individual’s
significant risk factors for developing pressure ulcers; for example, immobility, recent
weight loss and history of pressure ulcers.
-The nurse shall describe and document/report the location, stage, length, width, depth,
and presence of exudates or necrotic tissue.
-The policy did not instruct how often a resident’s skin should be assessed or what
unlicensed staff should do if they note any skin issues.
1. Review of Resident #17’s care plan, last revised 12/11/18, showed:
-Required assistance of two staff for transfers;
-Was incontinent and required total care;
-Turn every two hours with assistance of one staff;
-Was on hospice care;
-Did not address the resident’s past or present pressure ulcer, risk for pressure ulcers,
or other pressure ulcer prevention interventions or care other than turning.
Review of the skin inspection report for 1/7/19-1/27/19, showed:
-1/7/19, skin not intact-existing;
-1/15/19, skin not intact-existing;
-1/21/19, skin intact;
-1/27/19, skin intact.
Review of the resident’s quarterly Minimum Data Set (MDS), a
federally mandated assessment instrument completed by facility staff, dated 1/12/19,
showed:
-Total dependence for bed mobility, transfers, dressing, eating and bathing;
-Frequently incontinent of bowel and bladder;
-Had a stage I pressure injury (intact skin with non-blanchable tissue of a localized area
or over a bony prominence).
Review of the resident’s (MONTH) 2019 electronic physician order [REDACTED].
-No orders for wound care;
-an order for [REDACTED].
During an interview on 2/8/19 at 9:28 A.M., Licensed Practical Nurse (LPN) B said:
-The resident had a small open area on his/her bottom at one time, but did not think
he/she had one currently.
-The resident did not currently receive any wound care.
-LPN B only worked one day a week, so was not sure, and thought the sore was healed.
During an observation and interview on 2/8/19 at 11:38 A.M., Certified Nurse Assistant
(CNA) A provided the following care and said:
-Unfastened the resident’s brief and said the resident was wet and was incontinent of
fecal material;
-Cleansed the front genital area, then turned the resident to his/her side and cleansed
fecal material from the backside;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265762

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOSEPH SENIOR LIVING

STREET ADDRESS, CITY, STATE, ZIP

1317 NORTH 36TH STREET
SAINT JOSEPH, MO 64506

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
-A pea-sized open area with a pink center was located on the resident’s sacrum;
-There was no type of dressing over the open area;
-CNA A said the resident had an open area on his/her backside for a while and that hospice
nurses and facility nurses provided wound care, but was not sure what the treatment was;
-CNA A said that the CNA’s turned the resident when he/she was in bed and they did not
leave him/her up in a chair very long.
Review of the resident’s (MONTH) 2019 electronic treatment administration record (e-TAR)
showed weekly skin assessments done on 2/3/19 and 2/10/19 with skin documented as intact.
During an interview on 2/11/19 at 12:35 P.M., LPN A said:
-The resident had a pressure ulcer on his/her backside recently, but he/she thought it was
healed.
-LPN A showed the (MONTH) skin inspection report which showed non-intact skin with an
existing skin issue for 1/7/19 and 1/15/19, and entries for 1/21/19 and 1/27/19 that
showed intact skin.
-LPN A said the resident’s wound treatment was discontinued.
-He/she knew of no current open areas on the resident, but would assess the resident’s
skin when staff put him/her back to bed after lunch.
During an interview on 2/11/19 at 2:20 P.M., the assistant director of nurses (ADON) said
that the CNA’s do not document any skin issues, they should tell the nurse and the nurse
should document any skin issues.
During an interview on 2/11/19 at 2:25 P.M., LPN A said:
-He/she assessed the resident’s skin this afternoon and found a 0.5 centimeter (cm) by 0.5
cm open area on the resident’s coccyx that had no measurable depth.
-He/she obtained a treatment order and contacted hospice.
-He/she did not know why the nurse documented that the resident’s skin was intact during
the weekly skin assessment on 2/10/19 when the surveyor saw the open area on 2/8/19 and it
was still currently open.
-LPN A thought the open area was possibly covered with barrier cream when the night nurse
did the weekly skin assessment, so he/she did not see it.
-Staff should include the presence of a pressure ulcer in the care plan and in the nurses’
shift report to let staff know it was there.
During a phone interview on 2/11/19 at 3:47 P.M., the director of nurses (DON) said:
-Nurses do weekly skin assessments.
-CNA’s should report any skin issues to the nurse and the nurse should document the issue
in the progress notes or on the weekly skin audit sheet.
-Staff should document he size and character of the open area.
-Staff should also care plan for current pressure ulcers or for residents with a history
of past pressure ulcers.

F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that a nursing home area is free from accident hazards and provides adequate
supervision to prevent accidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
transferred residents in a manner that reduced the possibility of injury during gait belt
(belt secured around the resident’s waist for staff to grasp when assisting a resident to

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265762

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOSEPH SENIOR LIVING

STREET ADDRESS, CITY, STATE, ZIP

1317 NORTH 36TH STREET
SAINT JOSEPH, MO 64506

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
stand, transfer and walk) transfers for two out of 15 sampled residents (Residents #27 and
#17). The facility census was 58.
Review of the facility’s policy, entitled Safe Lifting and Movement of Residents, dated
(MONTH) (YEAR), showed:
-In order to protect the safety and well-being of staff and residents, and to promote
quality care, this facility uses appropriate techniques and devices to lift and move
residents.
-Staff responsible for direct resident care will be trained in the use of manual (to
include gait belts) and mechanical lifting devices.
1. Review of Resident #27’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 1/23/19, showed;
-Required limited assistance for transfers;
-Had one non-injury fall since the last MDS assessment.
Review of the resident’s care plan, last revised 2/5/19, showed:
-Required assistance of one for transfers;
-At risk for falls due to muscle weakness;
-Had non-injury falls on 1/23/19 and 2/4/19.
Observation on 2/8/19 at 9:58 A.M. showed Certified Nurse Assistant (CNA) A and CNA B
transferred the resident from a wheelchair to bed in the following manner:
-CNA A applied a gait belt around the resident’s upper chest, above the breasts, with the
gait belt against the resident’s arm pits.
-A CNA stood on each of the resident’s sides.
-CNA A grasped the gait belt in the front and back of the resident.
-CNA B grasped the gait belt in the back of the resident and placed his/her arm under the
resident’s arm pit.
-The resident’s shoulders raised upward as staff lifted the resident to stand.
-Both staff assisted the resident to pivot and sat him/her on the bed, removed the gait
belt and laid the resident in bed.
During an interview on 2/8/19 at 12:09 A.M., CNA B said:
-Staff should place the gait belt around the resident’s waist or above the breasts,
according to the resident’s choice.
-Staff should never lift under the resident’s arms.
2. Review of Resident #17’s care plan, last revised on 12/11/18, showed:
-Had altered activities of daily living related to dementia;
-Required assistance of two staff for transfers;
-Had a past history of falls.
Review of the resident’s quarterly MDS, dated [DATE], showed:
-Total dependence on staff for transfers;
-Had two non-injury falls and on fall with injury since the last MDS assessment.
During an observation on 2/8/19 at 11:38 A.M., CNA A and CNA C transferred the resident
from the bed to a wheelchair in the following manner:
-Staff provided incontinent care and dressed the resident.
-Staff assisted the resident to sit at the edge of the bed.
-CNA A applied the gait belt across the resident’s chest area.
-CNA A and CNA C stood at each side of the resident and each staff hooked one of their
arms under each of the resident’s arms, grasped the gait belt in the back of the resident
and lifted the resident to stand.
-The resident’s shoulders raised as staff lifted him/her.
-Staff pivoted the resident and sat him/her in the wheelchair.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265762

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOSEPH SENIOR LIVING

STREET ADDRESS, CITY, STATE, ZIP

1317 NORTH 36TH STREET
SAINT JOSEPH, MO 64506

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0689

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
During an interview on 2/8/19 at 11:59 A.M., CNA A said:
-He/she was taught, that if the resident had a bigger chest, staff could place the gait
belt on the upper chest.
-He/she did not know staff should not place the gait belt up high.
-Staff should not lift under the resident’s arms because it could cause a skin break due
to the belt rubbing and could dislocate the shoulder.
During an interview on 2/8/19 at noon, CNA C said:
-Staff should place the gait belt below the resident’s breasts.
-Staff should not lift under the arms.
During a phone interview on 2/11/19 at 3:47 P.M., the Director of Nurses (DON) said:
-Staff should place the gait belt around the resident’s waist.
-Staff should not place the gait belt above the breasts or under the arm pits.
-Staff should grasp the gait belt and should not place an arm under the resident’s arm pit
to lift the resident.

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
administered medications with an error rate of less than five percent. Staff made three
errors out of 25 opportunities for error, resulting in an error rate of 12%. This affected
two residents. The facility census was 58.
Review of the facility’s policy related to medication administration, revised (MONTH)
2012, showed;
-The individual administering the medication must check the label to verify the right
resident, right medication, right dosage , right time and right route of administration
before administering the medication.
Review of the website https://www.drugs.com/tips/[MEDICATION NAME]-patient-tips showed to
administer [MEDICATION NAME] (used to heal gastrointestinal ulcers and decrease risk of
new ulcer formation by reducing stomach acid) medication on an empty stomach, at least one
hour before a meal.
Review of the website https://www.drugs.com/dosage/[MEDICATION NAME].html showed to
administer [MEDICATION NAME] ([MEDICAL CONDITION] medication) on an empty stomach with
water, at least one half an hour before any food is eaten.
1. Review of Resident #27’s (MONTH) 2019 electronic physician order [REDACTED].
-1/4/19-[MEDICATION NAME] 75 micrograms (mcg) daily, scheduled for A.M.;
-[MEDICATION NAME] DR (delayed release) 20 milligrams (mg) one daily for acid reduction,
scheduled for A.M.
Review of the resident’s (MONTH) 2019 electronic Medication Administration Record
[REDACTED]
-[MEDICATION NAME] 75 mcg daily, scheduled for 8:00 A.M.;
-[MEDICATION NAME] DR 20 mg daily, scheduled for 8:00 A.M.
Review of the resident’s care plan, last revised on 2/5/19, did not address any special
instructions related to the administration of the resident’s [MEDICATION NAME] or
[MEDICATION NAME].
Observation and interview on 2/8/19 at 8:58 A.M., showed Certified Medication Technician

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265762

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOSEPH SENIOR LIVING

STREET ADDRESS, CITY, STATE, ZIP

1317 NORTH 36TH STREET
SAINT JOSEPH, MO 64506

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
(CMT) A administered the resident’s medications in the following manner, and said:
-Placed the residents [MEDICATION NAME] and [MEDICATION NAME] DR in a medication cup with
several other medications.
-Administered the medications to the resident in the dining room where the resident was
eating his/her meal, with about half eaten.
-Staff usually administer [MEDICAL CONDITION] medication and [MEDICATION NAME] before
breakfast, the first thing of a morning.
-This resident slept in and took his/her medications better when up, so staff waited until
he/she was out of bed.
2. Review of Resident #5’s (MONTH) 2019 e-POS showed an order, dated 1/7/19, for
[MEDICATION NAME] 20 mg three times a day with meals for malodorous urine.
Observation and interview on 2/8/19 at 12:16 P.M. showed CMT A administered the resident’s
[MEDICATION NAME] in the following manner and said:
-Checked the e-MAR;
-Removed the resident’s bottle of [MEDICATION NAME], with a label that indicated it
contained [MEDICATION NAME]-[MEDICATION NAME] 0.6 mg-3 mg per tablet, from the medication
cart,, placed one tablet in a medication cup and prepared to administer the medication to
the resident;
-When questioned about the dose, he/she said he/she had not previously noticed there was a
different dose on the medication bottle compared to the 20 mg dose on the e-MAR.
Review of the resident’s (MONTH) 2019 e-MAR showed staff administered [MEDICATION NAME] 20
mg three times a day with meals from 2/1/19 through the noon dose on 2/8/19.
During an interview on 2/8/19 at 12:33 P.M., the assistant Director of Nurses (ADON) said:
-He/she spoke with the resident’s physician and verified that the [MEDICATION NAME] dose
was 3 mg.
-The original [MEDICATION NAME] dose was 3 mg, but staff incorrectly entered it into the
new e-POS computer system.
During a phone interview on 2/11/19 at 3:47 P.M., the DON said:
-Staff should give resident medications according to resident wishes.
-The computer system gave staff two hours before and two hours after the time entered in
the computer, which was 8:00 A.M. for the A.M. medication pass, that way the resident can
decide when they want to take the medication.
-Most [MEDICAL CONDITION] medication and [MEDICATION NAME] are scheduled for the A.M.
medication pass.
-Staff usually administer [MEDICAL CONDITION] medications and [MEDICATION NAME] before
breakfast, but some residents do not get up before breakfast.
-Staff should care plan for residents who do not want to take these types of medications
before meals because they prefer to get up later.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
followed infection control protocols to prevent the spread of infection for one out of 15
sampled residents (Resident #48). The facility census was 58.
Review of the facility’s hand hygiene policy, dated (MONTH) (YEAR), showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265762

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOSEPH SENIOR LIVING

STREET ADDRESS, CITY, STATE, ZIP

1317 NORTH 36TH STREET
SAINT JOSEPH, MO 64506

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
-This facility considers hand hygiene the primary means to prevent the spread of
infections.
-All personnel shall be trained and regularly in-serviced on the importance of hand
hygiene in preventing the transmission of healthcare-associated infections.
-Wash hands with soap and water when visibly soiled and after contact with a resident with
specified infections, per policy.
-Use an alcohol-based hand rub before and after direct contact with residents, before
moving from a contaminated body site to a clean body site during resident care, after
contact with a resident’s intact skin, after removing gloves and after contact with
objects in the immediate vicinity of the resident.
-The use of gloves does not replace hand hygiene.
1. Review of Resident #48’s care plan, last revised 8/20/18, showed:
-Functional urinary incontinence related to injuries sustained in a motor vehicle
accident;
-Provide incontinence care after each incontinence episode.
Review of the resident’s quarterly Minimum, Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/1/18, showed:
-Totally dependent for all care;
-Had a urinary catheter (sterile tube inserted into the bladder to drain urine);
-Had a [MEDICAL CONDITION] (surgical opening from the colon through the abdominal wall)
for bowel elimination.
During an observation on 2/5/19 at 2:54 P.M., Certified Nurse Assistant (CNA) D and CNA E
provided care for the resident in the following manner:
-CNA D was already in the resident’s room with gloves on.
-CNA E brought a mechanical lift (device used to lift and transfer resident’s from one
place to another) into the room and put on gloves, but did not wash his/her hands first.
-Both staff transferred the resident from a wheelchair to the bed.
-CNA D provided incontinent care to the resident’s front genital area, and with the same
gloves on, sprayed peri cleanser to each pre-moistened wipe between each swipe, then
opened the resident’s bedside drawer and put the container of peri cleanser in the drawer.
-CNA E turned the resident to his/her right side and CNA D cleansed the resident’s
backside and disposed of the wet brief.
-Both staff placed a clean brief on the resident.
-CNA D removed his/her gloves, did not perform hand hygiene, and took a bag of soiled
items from the room.
-CNA D returned and washed his/her hands and put on gloves.
-CNA D removed the resident’s [MEDICAL CONDITION] bag, which contained fecal material, and
cleansed the area around the [MEDICAL CONDITION] stoma (hole created in the abdominal
wall), then with the same gloves on, placed the ostomy care supplies in the bedside
drawer.
-CNA E applied a new bag over the stoma, removed his/her gloves and washed his/her hands.
-CNA D did not remove his/her gloves and touched the resident in multiple areas as staff
dressed the resident, adjusted the lift sling (an assistive device a resident is placed in
that is attached to a mechanical lift), helped attach the lift sling to the mechanical
lift, touched the mechanical lift control, moved the mechanical lift to the wheelchair,
touched the control on the resident’s electric wheelchair, adjusted the resident’s feet,
touched the mechanical lift again in various places, touched the seat belt on the
resident’s wheelchair, put the resident’s shoes on him/her, put a pillow under the
resident’s feet, touched the wheelchair control again, then removed his/her soiled gloves,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 9/25/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265762

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

ST JOSEPH SENIOR LIVING

STREET ADDRESS, CITY, STATE, ZIP

1317 NORTH 36TH STREET
SAINT JOSEPH, MO 64506

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
put a blanket over the resident’s legs, made the bed, obtained perfume from the bedside
drawer, sprayed on the resident and returned it to the bedside drawer, then washed his/her
hands.
-CNA E removed his/her gloves and washed his/her hands.
During an interview on 2/8/19 at 3:22 P.M., CNA D said:
-Staff should sanitize their hands before and after they put on gloves, when they enter a
resident’s room and before they exit the room.
-Staff should remove their gloves and sanitize their hands when done cleansing one body
area before they cleanse the next area.
-Staff should remove their gloves and sanitize their hands after providing peri care and
before they touch anything else.
During a phone interview on 2/11/19 at 3:47 P.M., the Director of Nurses (DON) said:
-Staff should sanitize their hands when they enter, before they leave a resident room and
after each glove removal.
-Staff should remove their gloves and sanitize their hands after they provide peri care
and should not touch other items or surfaces with soiled gloves