Saint John Paul II Center

Inspectors wroteBased on clinical record review, facility documentation, facility policy and interviews for one sampled resident (Resident #1) who was reviewed for Resident Rights, the facility failed to ensure Resident #1's verbalization of his/her wish to have the specific family member who had been appointed as his/her health care representative prior to admission was acknowledged by the facility.

Inspectors wroteBased on record review, facility documentation, and staff interviews for one of three residents (Resident #1), reviewed for accidents, facility failed to ensure staff failed to notify the Registered Nurse (RN) supervisor after Resident #1 sustained a fall.

Inspectors wroteBased on record review, facility documentation, and staff interviews for one of three residents (Resident #1), reviewed for accidents, facility failed to ensure the resident was transferred in accordance with the plan of care.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one (1) of three (3) sampled residents (Resident #1) who were dependent on staff for transfers, the facility failed to ensure the appropriate number of staff, two (2), transferred the resident via a mechanical lift to prevent a minor injury.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one sampled resident (Resident #1) who was reviewed for an allegation of abuse, the facility failed to ensure Resident #1 was free from physical contact with a staff member.

Inspectors wroteBased on clinical record reviews, facility policy, facility documentation and interviews for one (1) of three (3) sampled residents (Resident #2) who had a change in condition, the facility failed to ensure care and services provided were in accordance with professional standards.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #2) reviewed for accidents, the facility failed to ensure a resident's neurological assessments were conducted following an unwitnessed fall.

Inspectors wroteBased on clinical record reviews and interviews for 4 of 5 residents reviewed for Unnecessary medication review (Residents #22, # 32, 58 and #86), the facility failed to ensure monthly pharmacy reviews were consistently completed.

Inspectors wroteBased on observations of the facility Medication Storage and labeling, facility policy and interviews reviewed for 2 of 3 (1 North and 2 South Units) medication rooms, the facility failed to ensure that an expired medication was discarded. The facility failed to ensure the fridge temperatures were consistently checked and documented and failed to ensure that refrigerators were locked, utilizing locks.

Inspectors wroteBased on observations of the dining, facility policy and interviews, the facility failed to ensure meals were served at the appropriate temperature.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents ( Resident # 71), reviewed for Preadmission Screening and Resident Review ( PASARR), the facility failed to ensure a newly identified mental health diagnosis was referred to appropriate state- designated mental health authority for a level 2 evaluation.

Inspectors wroteBased on review of the clinical record, review of facility policy and staff interviews for 1 of the 3 residents reviewed for Activities of Daily Living (ADL) for (Resident #111), the facility failed to ensure the resident consistently received scheduled showers.

Inspectors wroteBased on review clinical record reviews, observation, facility documents, review of policy and interviews for 1 of 4 residents reviewed for accidents (Resident #38), the facility failed to ensure a physician order was written for a diagnostic x-ray after a fall and for 1 of 1 resident reviewed for positioning (Resident #271), the facility failed to ensure the resident's cervical collar was positioned appropriately.

Inspectors wroteBased on clinical record review, observation, facility policy and staff interviews for the only resident reviewed for Pressure Ulcer (Resident #99), the facility failed to ensure a physician order was obtained for mattress setting for a specialty mattress and failed to ensure licensed staff checked the settings per the facility policy.

Inspectors wroteBased on clinical record, facility policy review and staff interview for 1 of 4 residents (Resident #117) reviewed for nutrition, the facility failed to ensure weights were obtained per facility policy for a resident with weight loss.

Inspectors wroteBased on review of employee files, facility documentation for skills competency and interview for 1 licensed staff (LPN # 8), the facility failed to ensure licensed staff completed clinical competency validations to provide nursing and related services to meet the residents' needs safely for the year 2024.

Inspectors wroteBased on clinical record reviews and staff interviews for 2 of 5 residents reviewed for (Residents # 26 and # 58) reviewed for vaccinations, the facility failed to obtain an influenza vaccine consent or refusal from the resident's responsible party.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for discharge, the facility failed to provide discharge education for a diabetic resident newly prescribed insulin and failed to ensure medication reconciliation prior to discharge resulting in a resident being discharged home without prescribed medications and supplies.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for medication administration, the facility failed to ensure the physician was notified when the resident refused medication.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to develop and implement a comprehensive care plan to address the resident's history of often refusing medications.

Inspectors wroteBased on clinical record reviews, review of facility documentation and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of personal property, the facility failed to ensure a blister pack that contained seven (7) tablets of a controlled medication, Oxycodone, and the controlled disposition sheet were not removed from the facility by a licensed nurse.

Inspectors wroteBased on clinical record reviews, review of facility policy, review of facility documentation, and interviews for one (1) of three (3) sampled residents (Resident #1) who were reviewed for the misappropriation of personal property, the facility failed to report an incident to the State Agency when the facility became aware a controlled medication was removed from the facility by a licensed nurse.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents,(Resident #1), reviewed for grievances, the facility failed to ensure residents are notified of the grievance resolution.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for neglect, the facility failed to ensure a resident who was incontinent of bowel and bladder received incontinent care in accordance to their plan of care resulting in a finding of neglect.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for neglect, the facility failed to report an allegation of neglect to the state agency within the required time frame.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 3 of 5 residents (Resident #91, 22 and 124) reviewed for accidents, for Resident #91, the facility failed to provide the physician ordered 1:1 supervision which resulted in a fall with injury, for Resident #22, the facility failed to provide adequate supervision to prevent a fall, and for Resident #124, the facility failed to ensure the bed was locked to prevent a fall, and for 1 of 5 residents (Resident #93) reviewed for unnecessary medications, the facility failed to ensure that pharmacy recommendations were reviewed and implemented for a resident with a history of multiple falls.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident #27, 105, 114 and 115) reviewed for care planning, the facility failed invite the resident/resident representative to participate in the care plan meetings. Additionally, the facility failed to ensure that residents who had a diagnosis of dementia were invited to care plan meetings.

Inspectors wroteBased on observation, review of facility documentation, review of job descriptions, and interviews the facility failed to ensure the environment was maintained in good repair and a homelike manner and failed to ensure environmental rounds are completed.

Inspectors wroteBased on review of facility documentation, facility policy, and interviews for 4 licensed staff (RN #5, RN #6, LPN #4, and LPN #5) the facility failed to ensure background checks were completed prior to hire.

Inspectors wroteBased on clinical record review, facility documentation, facility policy and staff interviews for 3 of 5 residents (Resident #93 and 115) reviewed for unnecessary medications, the facility failed to review and respond to pharmacy recommendations.

Inspectors wroteBased on a tour of the Dietary Department with the Food Service Director, and staff interviews the facility failed to provide lunch that was at appropriate temperatures. On 5/10/23 at 1:00 PM, a test tray was conducted. The following was identified: The lunch meal was plated and left the Dietary Department in 3 metal carts at 1:09 PM, arrived on the 2 North Unit and placed in the hall outside of the resident Dining Room at 1:09 PM. Nurse Aides (NA) were then observed to place beverages on the meal trays within the metal carts (juice, coffee and soda) from 1:09 PM to 1:15 PM. At 1:15 PM, the doors were closed to the 3 metal carts. At 1:20 PM, NAs were observed to keep opening the 6 doors to 3 metal carts looking for specific trays by reading the meal tickets. [...]

Inspectors wroteBased on a tour of the Dietary Department with the Food Service Director, facility policy and staff interviews, the facility failed to conduct appropriate hand hygiene and maintain the kitchen in a sanitary manner. Tour of the Dietary Department with the Food Service Director on 5/8/23 at 10:33 AM identified the following: 1a. The Unit 2 refrigerator which consisted of milk was noted to have green debris and white drip stains on the bottom shelf. b. Multiple ceiling exterior vent plates noted to have a heavy accumulation of grayish white marks. c. The ceiling vent grille above the shelf that holds the spices, seasonings and coffee machine was noted to have a heavy accumulation of black and brown sediment. d. The flour container labeled with an expiration date of 6/6/23 was noted to have a tannish brown drip stain inside the container. [...]

Inspectors wroteBased on review of facility documentation and interviews the facility failed to designate a specific individual (with the required training and qualification) to oversee the infection control program between 1/2023 through 5/2023, (5 months).

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews, for 1 resident (Resident #105), the facility failed to ensure advance directives were reviewed with the resident or resident representative on admission to ensure that their wishes were honored.

Inspectors wroteBased review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #107) the facility failed to ensure the physician and conservator were updated of a weight loss in a timely manner.

Inspectors wroteBased on clinical record review, facility documentation, and interviews for 2 of 5 sampled residents (Resident #26 and Resident #94) reviewed for Pre-admission Screening and Record Review (PASARR), the facility failed to obtain approval for long term care placement when the PASARR agency did not approve a long term care stay (Resident #26) and failed to complete a Level 2 determination when the 30-day approval stay expired (Resident #94).

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 5 residents (Resident #9, 91 and 115) reviewed for care planning, for Resident #9 the facility failed to develop a care plan related to a protective head covering, for Resident #91 the facility failed to revise and update the care plan after a fall with injury, and for Resident #115 the facility failed to revise and update care plan according to established timeframes.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #2) reviewed for unnecessary medications the facility failed to ensure the pharmacy recommendations were followed, and for 1 resident (Resident #79) reviewed for choices, the facility failed to assess the resident for the ability to consume alcohol while a resident at the facility.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #81) reviewed for limited range of motion, the facility failed to consistently implement measures and address the residents decline in range of motion to both hands.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Resident #49 and 107) reviewed for nutrition, the facility failed to obtain weights and reweights according to professional standards.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #23) reviewed for respiratory therapy, the facility failed to label and date oxygen tubing per facility policy.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #27) reviewed for specialized service, the facility failed to monitor fluid intake for a resident on a fluid restriction and per the physician's order.

Inspectors wroteBased on review of facility documentation, facility policy, and interviews the facility failed to ensure adequate staffing to meet the needs of the residents, including the provision of 1:1 monitoring per the physician's orders.

Inspectors wroteBased on clinical record review, facility documentation, facility policy and staff interviews for 1 of 5 sampled residents (Resident #115) reviewed for unnecessary medications, the facility failed to identify target behaviors for the use of psychotropic medication and failed to order as needed (PRN) psychotropics for only 14 days.

Inspectors wroteBased on observation, review of facility documentation, facility policy, and interviews, for 1 resident (Resident #23) reviewed for respiratory equipment, the facility failed to maintain oxygen tubing off the floor when not in use, and for 1 resident (Resident #79) reviewed for infection control, the facility failed to ensure supervision and resident education to maintain infection control when independently caring for his/her gastric tube (g-tube) and colostomy, and the facility failed to monitor and conduct quarterly analysis of infection trends within the facility.

Inspectors wroteBased on review of facility documentation, facility policy, and interviews for 2 nurse aides, the facility failed to complete annual performance evaluations.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure nurse staffing information was current and posted in an area visible to residents/visitors from the inside of the building.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #8) reviewed for behaviors, the facility failed to ensure that the clinical record reflected complete and accurate documentation related to continuous 1:1 observation and for 1 resident (Resident #114) reviewed for showers, the facility failed to ensure documentation was completed when the Nurse Aid provided Resident #114 a shower.

Inspectors wroteBased on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for 1 of 6 sampled residents (Resident #39) reviewed for Pre-admission Screening and Resident Review (PASARR), the facility failed to ensure that a referral was made to the state designated authority (Maximus) when the pre-approved thirty day stay had expired, which delayed the resident's level II PASARR being completed in a timely manner.

Inspectors wroteBased on clinical record review, review of facility documentation, review of facility policy, and interviews for one of five residents reviewed for unnecessary medication (Resident #89), the facility failed to follow the pharmacist recommendation.

Inspectors wroteBased on facility documentation, facility policy, and interviews for infection control reviewed for notification to all residents, families regarding confirmed Covid-19 infections by 5:00 PM the next calendar day, the facility failed to notify the residents and families of positive Covid-19 infections in accordance to the Centers for Medicare and Medicaid Services.