Living Community of St. Joseph

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medications used in the facility were labeled in accordance with professional standards, including expiration dates for seven sampled residents (Residents #10, #41, #46, #50, #79, #97, #102); when the facility had an open expired insulin pen (Resident #10); when the facility had an opened multi-use medicated nasal spray and eye drops with no open dates (Resident #79 & Resident #97); when the facility had an uncapped, pre-primed insulin needle and pen with dried blood on it (Resident #41); also when the facility had an opened large, floor stock powdered fiber medication with no open date, as well as two expired floor stock oral medications (Aspirin and guaifenesin); [...]

Inspectors wroteBased on observation and interview the facility failed to store food in accordance with professional standards for food service safety when the facility failed to ensure food items were dated with an open date or expiration date, and when the facility failed to dispose of food items that had been expired. This had to potential to affect all residents. The facility census was 87. Review of the facilities Food Storage- Perishable dated 2012, showed:-Sanitary procedures will be maintained in perishable food storage to keep foods safe, wholesome and appetizing, and to prevent contamination;-Refrigerated frozen products must be properly stored immediately upon delivery;-All prepared food stored in the refrigerator units should be in covered, seamless containers or otherwise suitably protected with used by date. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when the facility staff did not utilize enhanced barrier precautions by wearing appropriate protective equipment when caring for residents with an indwelling device for three residents (Residents #10, #37 & #39) and additionally when the facility staff did not change gloves between dirty and clean tasks for one resident (Resident #39); this affected three of the 18 sampled residents. The facility census was 87. [...]

Inspectors wroteBased on interview and record review, the facility failed ensure one of 6 sampled residents (Resident #1) received adequate assistance and supervision to prevent accidents when the facility staff transferred the resident to a standing position without a gait belt. The resident ambulated to the restroom, notified staff that he/she felt dizzy, the staff member left the resident alone to go obtain a gait belt and the reisdent fell. The resident fractured his/her left hip and required surgery. The facility census was 77. Review of the facility policy titled, Integrated Fall Management Policy, dated 8/24/17, showed: -Fall Risk assessments are to be completed quarterly and upon significant change of condition; -Identify other risk factors in the Minimum Data Set (MDS) to identify additional risk factors and interventions; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two of 25 sample residents (Resident (R) 54 and R23) reviewed for self-administration of medications were permitted to exercise their resident rights. Specifically, the facility failed to ensure medications were not left at the bedside of R54 who was not assessed to be able to self-administer medications safely; and the facility failed to ensure R23, who desired to self-administer medications and was assessed to be safe to do so was permitted to. The facility census was 80.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to conduct a thorough investigation of an allegation of verbal abuse by a staff member for two of two residents (Resident (R) 26 and R32) reviewed for abuse out of a total sample of 25. This failure created the potential for abuse of other residents. The facility census was 80.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure two of 25 sampled residents (Residents (R)37 and R21) were provided with sufficient supervision and assistive devices to prevent accidents. R37 experienced a fall in which she fell forward out of the bed onto the floor on 09/20/24. There was a lack of interventions implemented in response to the fall and seven days later, R37 experienced another fall onto the floor. R37 sustained injuries including abrasions to her knees, a nosebleed, bleeding gums, bruise to her right cheek, and experienced hip and knee pain. R21 wandered through out the First-Floor [NAME] unit and into residents' rooms, including the rooms of R37 and R32, putting herself and other residents at risk of injuries. [...]

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of 25 sampled residents (Resident (R) 21) residents had an accurate Minimum Data Set (MDS) assessment. This had the potential to cause the resident to have unmet care needs. The facility census was 80.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to have an end date for an as needed (PRN) psychotropic medication for two of six residents (Resident (R) 16 and R282) reviewed for unnecessary medications out of a total sample of 25. The failure had the potential for residents to receive psychotropic medications without ongoing assessment by a physician or practitioner for continued appropriateness. The facility census was 80.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the medical record was accurate and complete for one out of 25 sampled residents (Resident (R) 37). R37's record did not include the updated Preadmission Screening and Resident Review (PASRR) Level 1 form, and R37 was documented with a serious mental illness diagnosis of bipolar disease that was not accurate. This created the potential for R37 to experience the stigma associated with mental illness and for staff and medical providers not to have full and accurate information about R37's mental health condition. The facility census was 80. [...]

Inspectors wroteBased on record review and interview, the facility failed to hold residents' monies separate from facility money when they did not reimburse residents and/or their responsible parties after the residents were discharged , which affected six residents (Residents #994, #995, #996, #997, #998, and #999). The facility census was 95. Review of facility policy, Refunds - Credit Balances, dated [DATE], showed: -Purpose: To prevent fraud, waste, and abuse and manage reimbursement; -Policy: All credit balances will be reviewed within 30 days from being identified. Under the Patient Protection and Affordable Care Act, Title VI entitled Transparency and Program Integrity section 6402; overpayments from Federal payers must be refunded within 60 days after the date on which the overpayment was identified. [...]

Inspectors wroteBased on the record review and interview, the facility staff failed to check the Certified Nurses' Assistant (CNA) Registry for all staff to ensure they did not have a Federal Indicator (a marker given by the federal government to individuals who have committed abuse/neglect). This affected four of ten sampled staff (Cook A, Housekeeper A, Physical Therapy Assistant, Culinary Services Aide F). The facility census was 95. Review of the facility policy, Abuse Prevention Plan, dated 7/21/22, showed: -All potential employees will be screened during the hiring and re-hiring process for a history of abuse, neglect, financial exploitation, misappropriation of resident property, or mistreatment of a vulnerable adult; -Inquiries will be made into the state licensing authorities or Nursing Assistant Registry; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they completed and submitted to Centers for Medicare and Medicaid (CMS) comprehensive Minimum Data Set (MDS, a federally mandated assessment completed by staff) according to the required timeframes. This affected two of 19 sampled residents (Residents #28 and #84). The facility census was 95. Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed: - A facility must conduct a comprehensive assessment of a resident as follows: a. Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. b. Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they completed, submitted to Centers for Medicare and Medicaid (CMS) and they accepted the Minimum Data Set (MDS, a federally mandated assessment completed by staff) on a quarterly basis. This affected six of 19 sampled residents (Residents #28, #68, #75 #84, #87, and #227). The facility census was 95. Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed: - A facility must conduct a comprehensive assessment of a resident as follows: c. Using the quarterly review instrument specified by the State and approved by Center for Medicare and Medicaid (CMS) not less frequently than once every 3 months. - Within seven days after a faciltiy completes a resident's assessment: a. A facility must enter the MDS information into a computer. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they completed and transmitted to Centers for Medicare and Medicaid (CMS) and they accepted the Minimum Data Set (MDS, a federally mandated assessment completed by staff) according to the required timeframes. This affected six of 19 sampled residents (Residents #28, #68, #75, #84, #87, and #227). The facility census was 95. Review of the facility's Comprehensive Assessments and Care Planning policy, dated 2017, showed: - A facility must conduct a comprehensive assessment of a resident as follows: a. Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. b. Within 14 days after the facility determines, or should have determined, that there has been a significant change int he resident's physical or mental condition. c. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to assure staff used the residents' comprehensive assessments to develop and implement a comprehensive person-centered plan of care consistent with the resident rights that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for four of 19 sampled residents (Resident #55, #89, #120 and #382). The facility census was 95. Review of the facility provided Comprehensive Care Plan Workload document, dated 9/1/22, showed: - The Minimum Data Set (MDS: a mandated assessment tool completed by the facility) Coordinator will use the Baseline Care Plan to build a Comprehensive Care Plan. Review of the Comprehensive Assessments and Care Planning policy, dated 2017, showed: - Purpose: [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to review and revise the comprehensive care plan to address residents who have had a significant change in health care status and dependent upon staff to carry out their activities of daily living for one sampled resident (Resident #95) out of 19 sampled residents. The facility census was 95. Review of the facility's undated policy for care plans showed: [...]

Inspectors wroteBased on observation, interview and record review, record review, the facility staff failed to ensure they provided care and treatment in accordance with professional standards of practice for two of 19 sampled residents (Resident #41 and #78) when staff failed to label and date a dermal patch for Resident #41 and failed to clarify a physician's order for scheduled nasal spray for Resident #78. The facility census was 95. Review of the facility's undated Physician Service Policy, showed: - All physician's orders will be followed as prescribed; - If physician's orders are not followed the reason shall be recorded in the resident's medical record. Review of the facility's Transdermal Drug Delivery System (patch) Policy, revised, August, 2014 showed: - Remove the old patch; - Label patch with date and nurses initials; - Apply new patch firmly to skin. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain good personal hygiene for two of 19 sampled residents (Resident #39 and #95) who required assistance to perform activities of daily living. The facility census was 95. Review of the undated facility policy for activities of daily living showed: - The purpose is to provide residents with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). - Residents unable to carry out ADLs independently will receive the services necessary to maintain grooming and personal hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to date and time enteral feeding bag (bags that are used with feeding pumps) to ensure residents receiving nutrition via feeding tube (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation) are not receiving spoiled formula, for one resident (Resident #382) out of nineteen sampled residents. The facility census was 95. Review of the undated facility policy for Monitoring Residents Receiving Enteral Feedings (a form of nutrition that is delivered into the digestive system as a liquid) showed: - The nutritional status of resident's who receive enteral nutrition/feedings will be evaluated and monitored on an ongoing basis by the Dietitian/designee to assure their nutritional needs are being met. - Procedure: [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure staff provided proper respiratory care for four of 19 sampled residents (Residents #1, #78, #95 and #120) when staff failed to properly clean oxygen concentrator filters and when staff failed to follow orders for oxygen therapy. The facility census was 95. Review of the facility's undated physician service policy showed: - All physicians' orders will be followed as prescribed; - If physicians' orders are not followed the reason shall be recorded in the resident's medical record. Review of the facility's oxygen therapy policy, dated 6/12/04, showed: - Oxygen therapy is initiated per a physician's order; - A specific order for liter flow must be ordered by the physician; - Adjust the liter flow according to physician's order; - Document the oxygen setting in the medical record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff administered medications with a medication error rate of less than 5%. Facility staff made six medication errors out of 25 opportunities for error, resulting in a medication error rate of 32%. This affected three residents sampled for medication administration (Residents #1, #41, and #78). The facility census was 95. Review of the facility's Medication Administration Procedures Policy, dated December 2017, showed: - Oral Medication Administration: o Wash hands when beginning a medication pass; o Avoid touching the tablet or capsule unless wearing gloves. - Eye Drop Administration: o With gloved finger, gently pull down lower eyelid to form a pouch while instructing the resident to look up; o Instruct resident to close eye; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store drugs and biologicals in a locked storage area to ensure drugs and biologicals were inaccessible to residents when medications were found in four residents' (Residents #1, #5, #15, and #78) rooms with no physicians' orders and failed to discard expired medications when expired medications were found in the rooms of three residents (Residents #1, #15 and #78). The facility census was 95. Review of the facility's policy, storage of medication in the facility, dated August 2014, showed: - It is the policy of the facility to ensure proper and safe storage of medications; - Outdated and contaminated medications are to be immediately removed from inventories; -No expired medication will be administered to residents. 1. Review of Resident #1's physician's order sheet (POS), dated 2/2/23 through 3/2/23, showed: [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure staff served food to the residents that was palatable, attractive, and served at a safe and appetizing temperature to the residents when hot food was not served at an appetizing temperature to eight of nineteen sampled residents (Resident #30, #73, #88, #89, #91, #229, #232, and #284). The facility had a census of 95. Review of the facility policy, Maintaining Proper Food Temperature during Food Service, dated 2012, included the following: -Food will be maintained at proper hot and cold temperatures prior to and during meal service to assure food quality and tastiness/palatability as well as food safety; -Temperature of hot food will be 135 degrees or higher during tray assembly; -Temperatures of cold food foods will be 41 degrees Fahrenheit or less during tray assembly; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to serve meals according to scheduled meal times. This affected five of nineteen sampled residents (Resident #2, #12, #30, #88, and #232) This had potential to impact all residents residing in the community. The facility census was 95. The facility did not provide a policy on meal times. 1. Review of the signs posted in the main dining rooms on each floor showed: -West hallway kitchenettes; -Breakfast 7:30 A.M. -Lunch 12:00 P.M. -Dinner 5:30 P.M. -South hallway kitchenettes; -Breakfast 8:15 A.M. -Lunch 12:45 P.M. -Dinner at 6:15 P.M. 2. Observation of lunch service on the second floor on 2/27/23 showed: -Cold food loaded onto food carts 11:39 A.M.; -Hot food loaded onto food carts at 12:07 P.M.; -Food carts leaving kitchen to provide meal service 12:16 P.M.; [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to store, prepare, and serve food in accordance to professional standards of food service safety when staff failed to fully date opened items, utilize proper hand washing, and failed to ensure all areas of the kitchen and food storage areas remained clean (dry food storage, walk through cooler, food prep counter, and food transport carts). The facility census was 95. 1. Review of the facility policy, Food Storage-Perishable, dated 2017, included: -All storage that takes place in refrigerated and freezer areas will be maintained in a clean, sanitary condition; -All food items must be stored on shelving or drainage racks that allow the entire floor to be completely cleaned; -To facilitate floor cleaning, the lower shelf in walk-in coolers and freezers should be a minimum of six inches above the floor; [...]