St Genevieve Nursing

Based on interview and record review, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: Medicare requires SNFs to issue a SNF ABN to beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary or considered custodial) to two residents (Residents #31 and #44) out of two sampled residents who were discharged from Medicare Part A services with benefit days remaining and continued to reside in the facility. The facility's census was 57.Review of the Form Instructions: Advance Beneficiary Notice of Non-coverage, undated, showed:- When Medicare is not likely to cover a specific item or service, healthcare providers and suppliers must use this ABN to let the patient know they may be financially liable before they get the items or services;- Notifiers must deliver the ABN to the patient or their representative before providing the items or services; review the ABN with the patient or their representative and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital and failed to provide a copy of the bed hold policy upon transfer to the hospital for four residents (Residents #8, #13, #40, and #44) out of four sampled residents. The facility also failed to notify the ombudsman (a trained advocate who investigates and resolves complaints made by or on behalf of residents in nursing homes, assisted living, and other residential care facilities) of the transfers. The facility's census was 57.Review of the facility's Bed Hold Policy and Agreement Form, revised February 2014, showed:- The purpose is to establish policy and procedure for the facility to notify the resident/responsible party of the Bed Hold Policy and Agreement To Pay Charges For Bed Hold. The facility is to execute an acknowledgement stating whether or not such resident desires to exercise his or her right to a bed hold. The policy should meet applicable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program met at least quarterly, as evidenced by a lack of documented QAPI meetings over an extended period. This had the potential to affect all residents by limiting the facility's ability to identify and address quality of care and safety concerns. The facility census was 57. The policy provided by the facility did not address quarterly QAPI meetings. Review of QAPI meeting documentation, provided by the Administrator in Training, showed:- A QAPI meeting was held on January 21, 2025; - A QAPI meeting was held on April 22, 2025;- A QAPI meeting was held on May 20, 2025;- A QAPI meeting was held on February 10, 2026;- No documentation of QAPI meetings conducted between May 20, 2025, and February 10, 2026 (approximately eight months); - No documentation the QAPI program was implemented on a consistent and ongoing basis during this time period. During an interview on 03/26/26 at 12:15 P.M., the Administrator, Administrator in Training, and Regional Business…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices during catheter (a flexible tube inserted into the bladder to drain urine) care for one resident (Resident #3) out of one sampled resident with a catheter and during wound care for one resident (Resident #33) out of one sampled resident with a wound. The facility's census was 57. Review of the facility's policy titled, Catheter Care, undated, showed: - Wash hands, gather equipment, and take to bedside; - Explain procedure to resident and screen for privacy; - Position resident; - Put on gloves; - Wash perineum (genital area) well with soap and warm water or peri-wipes, taking care to wash from front to back; - Clean area at catheter insertion site well, taking care not to pull on catheter or advance further; - All debris must be removed from catheter at insertion site; - Discard disposable equipment properly; - Position resident comfortably with call light in reach; - Wash hands. Review of the facility's policy titled, Enhanced Barrier Precautions, revised 12/12/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff provided care for two residents (Resident #7 and #27) out of 14 sampled residents and three residents (Resident #32, #33, and #38) outside the sample, in a manner that maintained their dignity when staff stood while feeding the residents. The facility's census was 53. The facility did not provide a policy. Observation on 11/04/24 at 12:24 P.M. of the dining room showed: - Nursing Assistant (NA) B stood over Resident #32 to feed him/her; - Resident #7, #27, #33, and #38 sat together at a separate table; - Certified Nursing Assistant (CNA) A stood over Residents #7 and #27 while assisting them with eating; - CNA A moved back to Resident #27 and stood over him/her while assisting him/her with eating; - CNA A moved back to Resident #27 and stood over the resident to feed him/her; - NA B then joined the table and stood over Resident #7 to feed him/her. - CNA A and NA B then both stood over Residents #38 and #33 to feed them; - NA B then returned to Resident #32's table and stood over him/her to assist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow their policy to ensure the Criminal Background Check (CBC), Employee Disqualification List (EDL - a listing of individuals who have been determined to have abused or neglected, misappropriated funds or property from a resident) and the Nurse Aide (NA) Registry were completed prior to the employment start date for two employees out of 10 sampled employees. The facility census was 53. Review of the facility's policy titled, Abuse, Prevention and Prohibition, revised 2021, showed: - The facility's abuse prohibition program includes the following seven components: Screening, Training, Prevention, Identification, Investigation, Protection, and Reporting/Response; - All employees will have criminal background checks, state and federal required checks, employment reference checks (previous and current), and license/certification confirmation. Review of the facility's policy titled, Corporate Compliance Process, undated, showed: - Criminal background checks are conducted on all potential employees and volunteers in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were given. There were 28 opportunities with two errors made, for an error rate of 7.14%. This affected one resident (Resident #13) out of 14 sampled residents. The facility census was 53. The facility did not provide a policy related to insulin administration. Review of Humalog Kwik Pen directions, revised July 2023, showed: - Pull the pen cap straight off; - Check the liquid in the pen; - Select a new needle; - Push the capped needle straight onto pen and twist the needle on until it is tight; - Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; - To prime pen, turn the dose knob to select two units; - Hold pen with needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops and 0 is seen in the dose window; - Insulin should be seen at the tip of the needle, if none is seen,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility staff failed to follow appropriate infection control practices while assisting two residents (Resident #7 and #27) out of 14 sampled residents and three residents outside the sample (Resident #32, #33 and #38) with their lunch meal. The facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility's census was 53. Review of the facility's policy titled, Dietary Policies, undated, showed: - Develop and maintains dietary services polices and procedures; - Assists with infection control and safety policies; - Ensures objectives and philosophy are understood and maintained by dietary staff; - Alerts administrator of existing or potential problem areas; - Ensures sanitary environment for food preparation and proper cleansing of equipment; - Ensure proper storage of foods to protect it from contamination. Review of the facility's policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain appropriate infection control practices for two residents (Resident #13 and #41) out of 14 sampled residents and one resident (Resident #14) outside the sample when facility staff did not perform hand hygiene between finger stick blood sugar (FSBS) checks and insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) administration and failed to disinfect the glucometer (a machine used to measure blood sugar) per the manufacturer's recommendations. The facility's census was 53. Review of the facility's policy titled, Cleaning and Disinfecting Blood Glucose Meters, dated 2019, showed; - Apply gloves before performing a blood glucose test. Glucose monitoring, administration of insulin, and any other procedure that involves potential exposure to bodily fluids; - Remove gloves and perform hand hygiene; - Apply new gloves; - Thoroughly clean all visible soil or organic material (e.g. blood) from glucometer before disinfection; - Perform hand hygiene (i.e. hand washing with soap…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kitchens, which prepared food for all residents. This deficient practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 52. Review of the facility's current employee list, dated 06/15/23, showed a hire date of 08/13/18 for the Dietary Supervisor (DS). During an interview on 09/13/23 at 3:00 P.M., the DS said he/she has worked for the facility about five years and has been the DS for about three years. The DS said he/she had started the certification classes, but did not finish them. The DS said the Administrator is supposed to help get him/her back in the class. The DS said he/she is not enrolled at this time and does not know when he/she will be enrolled. During an interview on 09/14/23 at 11:33 A.M., the Administrator said she would expect the DS to be certified after working for the facility for five years. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. This deficient practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 52. Observation on 09/12/23 at 8:45 A.M. of the kitchen showed: - [NAME] crusty build up on top of the dishwasher; - Bucket of pot and pan detergent sitting on the floor under the dishwashing sink; - Bucket of sanitizer sitting in the floor under the handwashing sink; - Ice build up on the freezer door approximately 6 inches at the top right corner, ice build up approximately 6 inches on the bottom right corner of the freezer door, condensation on the outer flange of the freezer and condensation on the floor outside the freezer door. Approximately ¼ inch thick layer of ice on the floor inside the freezer approximately 1 foot wide x 4 feet in length. Approximately 4 inches in width x 7 inches in length icicle formation hanging down in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to maintain quarterly Quality Assurance & Performance Improvement (QAPI) meetings with the required members. The facility's census was 52. Review of the facility's Quality Assurance policy and procedure, undated, showed: - The Administrator will establish a Quality Assurance Committee that will coordinate the review of Quality Assurance activities within the facility organizational plan; - The Administration shall provide equipment, personnel, and support necessary to maintain the Quality Assurance program. 1. Review of the QAPI Quarterly Meeting sign in sheet, dated 04/18/23 and provided by the Administrator, showed the Infection Preventionist (IP) did not attend the meeting. 2. Review of the QAPI Quarterly Meeting sign in sheet, dated 07/27/23 and provided by the Administrator, showed the IP did not attend the meeting. During an interview on 09/13/23 at 11:11 A.M., the IP and Director of Nursing (DON) said the facility has no alternate certified IP. The DON is going to work on getting other staff certified so they will have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.