Josephine Caring Community

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident choices/preferences regarding their bathing schedule were honored for 3 of 4 sampled residents (Residents 2, 3, and 4) reviewed for choices. These failures placed the residents at risk for decreased cleanliness, increased risk of infection and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure quality of care and services was provided for 2 of 3 sampled residents (Residents 1 and 2) reviewed for skin, positioning, and assistance with meals. These failures placed residents at risk of medical complications and a diminished quality of life.

Inspectors wroteBased on observations and interview the facility failed to ensure drugs and biologicals were stored in accordance with the state and federal laws appropriately for 1 of 2 (Rehab Unit) Medication Storage Rooms. The facility failed to ensure Schedule II-V (Substances with high potential for abuse which may lead to severe psychological or physical dependence) controlled medications were in separate locked, permanently affixed compartments not accessible to others. These failures left controlled substances unattended with potential of unauthorized access to drugs that should have been securely stored.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 5 of 11 residents (Residents 5, 8, 74, 78, and 100) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected the physician visit documentation for 3 of 6 residents (Residents 5, 78, and 100), failed to include dialysis provider notes for 1 of 3 residents (Resident 74), failed to ensure accurate documentation for advanced directives for one of one resident (Resident 8). This failure placed residents at risk for medical complications, unmet care needs, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to coordinate with the preadmission screening and resident review program (PASARR) for 1 of 5 residents (Resident 8) reviewed for PASARR coordination. Resident 8 required a level II evaluation (in depth evaluation of a resident by the state designated authority) for a serious mental disorder which was not completed which placed residents at risk for unmet behavioral care needs. Findings Included. Resident 8 was admitted to the facility on [DATE], discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. Resident 8's diagnoses included Parkinson's disease, depression and dementia with psychotic features (hallucinations or delusions). Review of Resident 8's PASARR Level I (screening tool for possible serious mental illness) dated 01/10/2025 documented they required a level II evaluation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident care plans were updated for 1 of 1 residents (7) reviewed for Hospice services and 1 of 1 residents (100) reviewed for dental services. This failure placed residents at risk for decreased quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards were met for 1 of 1 resident (Resident 38) reviewed for oxygen, and 1 of 3 residents (Resident 13) reviewed for diabetic (disease that affects the blood sugar levels in blood) management. The facility failed to follow physician's orders for oxygen administration and failed to ensure appropriate monitoring for diabetes was completed based on national standards. These failures placed the residents at risk for adverse outcomes, medication errors, complications, and unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and provide pain management to adequately control residents pain for 1 of 3 residents (Resident 63) reviewed for pain management. This failure put residents at risk of uncontrolled pain and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify, assess, and address potential signs and/or symptoms of Post Traumatic Stress Disorder (PTSD) for 1 of 1 sampled resident (Resident 28), reviewed for mood and behavior. This failure placed residents at risk of re-traumatization, unmet behavioral health needs, and diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to ensure timely physician visits (once every 30 days for the first 90 days after admission) were completed for 4 of 7 residents (5, 49, 79 and 84) reviewed for physician visits. This failure placed residents at risk of being denied face-to-face contact with a physician, comprehensive reviews and physician assessments of their health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide timely laboratory results to meet the needs of one of two residents (121) reviewed for laboratory services. This failure had the potential for negative complications related to delay of obtaining and receiving follow up of laboratory results placing residents at risk for delay in treatment and adverse outcomes.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff adhered to infection control practices when providing care to 1 of 3 (Resident 78) residents that were on Transmission-Based Precautions. The facility failed to ensure staff used appropriate hand hygiene and personal protective equipment (PPE - equipment worn to minimize exposure to infections or diseases) when entering a room that had a sign of Contact Enteric Precaution (combination of contact precaution and enteric precautions used for infections that spread through contact with fecal matter or contaminated objects). This failure placed residents and staff at risk for potential infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently and accurately obtain weights, recognize significant weight loss, and provide consistent assistance with eating and cueing for 1 of 4 sampled residents (Resident 33) reviewed for nutrition. Resident 33 experienced a significant 14.6% weight loss from 05/27/2024 to 07/10/2024. This failure placed the resident at risk for further decline in their weight, unintended consequences of poor nutrition, and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to transport and serve food in a sanitary manner in 3 of 3 units (East, West, North) reviewed for food service. The failure to cover cold foods like fruit cups and desserts placed residents at risk for receiving contaminated foods and for diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a system was in place in which residents' records were complete, accurate, accessible, and systematically organized for 6 of twelve residents (33, 49, 78, 92, 103, and 107) reviewed for accurate and complete medical records. The facility failed to ensure the medical records reflected the accurate, and complete weights and bathing documentation for 2 residents (33, and 49), failed to contain the consents for use of restraints for 1 resident (92), failed to include consultant provider notes for podiatry and wound clinic documentation for 2 residents (78, and 103), failed to ensure accurate documentation for meal tray monitoring for 1 resident (92), and failed to ensure accurate documentation for a urinary catheter for one resident (107). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive, person-centered care plans to meet the needs and preferences for 1 (Resident 92) of 6 sampled residents reviewed for nutrition, 1 (Resident 7) of 5 sampled residents reviewed for unnecessary medications, 2 (Resident 87 and 92) of 2 sampled residents reviewed for restraints, and 1 (Resident 73) of 1 sampled resident reviewed for bowel and bladder. This failure placed residents at risk for not receiving needed, preferred care and services and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the assistance with activities of daily living (ADL's) for 2 of 7 sampled dependent residents (10 and 33) reviewed for ADL's. The facility failed to provide showers/bathing assistance to a resident (Resident 10), who was dependent on staff for bathing, and failed to ensure a resident that was dependent for assistance with meals was provided the necessary assistance. These failures placed the residents at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to offer appropriate services and assistance to maintain or improve mobility and range of motion for 1 of 1 sampled resident (Resident 107) reviewed for restorative nursing program. This failed practice placed the resident at risk for losing strength and range of motion they gained while receiving therapy services.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 15) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure a medical provider assessed and documented a rationale for extended use of an as necessary (PRN) anti-psychotic (medication that treats symptoms that affect the mind, and reality) medication for use over 14 days and provided no duration of use of the anti-psychotic medication. These failures placed the residents at risk for medication-related complications and for receiving unnecessary psychotropic medication.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure dependent residents received assistance with activities of daily living to include grooming for 1 of 1 resident (18) and bathing for 4 of 6 residents (61, 84, 91, and 102) in accordance with their needs and preferences reviewed. This failure placed residents at risk for diminished dignity, decreased quality of life and poor hygiene.

Inspectors wroteBased on interview and record review, the facility failed to ensure non-medication interventions were attempted prior to administration of psychoactive medications (medications that affect the mind or behavior), for two of five residents (7 and 68) and failed to monitor and evaluate for potential adverse side effects related to use of psychotropic medication for one of five residents (36) reviewed for unnecessary medications. This failure put the residents at risk for receiving and/or experiencing adverse side effects from unnecessary medication use and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods were prepared and served in a sanitary environment and that safe food practices were maintained in the facility kitchen. Failure to: 1) test chemical rinse concentrations for pots/pans sanitation, 2) ensure kitchen overhead light fixtures were free of dust and debris, 3) ensure dietary staff utilized hair restraints, and 4) to ensure potentially hazardous foods that were to be used at a later date were cooled using time/temperature controls for safety, placed residents at risk for foodborne illnesses and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reasonable accommodation of resident needs and preferences for 1 of 1 residents (Resident 60) reviewed for accommodation of needs. Failure to ensure residents received requested or alternate mobility equipment in their room placed them at risk for diminished independent functioning, dignity, and comfort.

Inspectors wroteBased on interview and record review the facility failed to recognize and ensure that allegations of abuse were reported to the State Agency within the required timeframe for one of two residents reviewed for abuse (102). This failed practice placed residents at risk for potential harm due to unrecognized abuse/neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 3 residents (83) with limited range of motion received appropriate treatment and services to increase range of motion (ROM) or prevent further decrease in range of motion. This failed practice placed the resident at risk for further declines in their ROM.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three residents (112) received adequate assessment and monitoring of unexpected weight loss. This failure placed residents at risk for experiencing further weight loss and failing to maintain adequate nutrition/hydration status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist conducted thorough reviews and identified relevant irregularities for 1 of 5 residents (36) reviewed. The failure to identify a lack of adverse side effect monitoring for antipsychotic medication treatment for several months placed the resident at risk for unidentified medication-related irregularities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications and biologicals were labeled and stored in accordance with applicable state and federal laws for two of seven medication carts. This failure placed residents at risk to receive incorrect medications, possible side effects, harm, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide assistance and follow up on an appointment for dental care services for one of one sampled resident, (102) reviewed for dental services. This failure placed the resident at a potential risk for continued dental needs, discomfort, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff used appropriate hand hygiene practices during wound care for one of one residents (81) reviewed for pressure ulcers. This failed placed Resident 81 at risk for wound infection.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice to 1 of 2 residents (57) and/or their responsible party of the resident's transfer to the hospital. The facility also failed to send a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman. Failure to provide the written notice disallowed the resident/responsible party an opportunity to fully understand the rationale and resident rights associated with the resident's discharge.