Saint Joseph Care Center

Inspectors wroteBased on observation, medical record review, staff and representative interview, and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to ensure monitoring and assessments were completed timely and appropriately for pressure ulcers and wound care was completed as ordered. This affected two residents (#5 and #61) of three reviewed for pressure wounds. The facility census was 57. Actual Harm occurred beginning on 11/04/25 to Resident #5, who was cognitively impaired, at risk for pressure ulcer development and required staff assistance for activities of daily living care, when the resident was identified to have moisture associated skin damage (MASD) to the coccyx that went unassessed and unmonitored resulting in a decline of the wound. [...]

Inspectors wroteBased on review of the CASPER Report 1705D (Staffing Report) for quarter three of fiscal year 2025 ([DATE]- [DATE]), review of facility nursing schedules, facility daily staffing report postings, and interview with staff, the facility failed to ensure eight consecutive hours of registered nursing coverage per day. This had the potential to affect all residents residing in the facility. The facility census was 57.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to maintain a clean and sanitary dumpster area. This had the potential to affect all residents residing in the facility. The facility census was 57.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure residents receiving puree diet were served the appropriate portion size and complete menu items. This affected five residents (#5, #6, #8, #9, and #11) of five identified as receiving a puree diets. The facility census was 57.

Inspectors wroteBased on review of medical records, review of facility policies, self-reported incident review, and resident and staff interviews, the facility failed to investigate and self-report an alleged incident of verbal abuse. This affected one (#3) of one residents reviewed for abuse. The facility census was 57.

Inspectors wroteBased on review of medical records, facility policy review, self-reported incident review, and resident and staff interviews, the facility failed to investigate an alleged incident of staff to resident verbal abuse. This affected one (#3) of one resident reviewed for abuse. The facility census was 57. Findings Include: Review of the medical record of Resident #3 revealed admission to facility on 09/18/20 with diagnoses of Parkinson's disease (progressive disease affecting balance and fine motor skills), depression, atrial fibrillation (irregular heart rate), anxiety, post-traumatic stress disorder, high blood pressure, and chronic constipation. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure comprehensive assessments were complete and accurate. This affected four (#4, #5, #22, and #43) of 22 residents reviewed for accurate comprehensive assessments.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure residents had accurate care plans. This affected two residents (#10 and #45) of 22 residents reviewed for accurate care planning.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure a resident had interventions in place for monitoring of congestive heart failure. This affected one resident (#17) of one resident reviewed for congestive heart failure (CHF).

Inspectors wroteBased on observation, record review, and interview, the facility failed to honor resident food preferences. This affected two residents (#17 and #43) of three residents reviewed for nutrition.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate enhanced barrier precaution signage was in place and appropriate isolation gowns were used when completing wound care. This affected two (#5 and #61) of three residents reviewed for pressure ulcer wounds.

Inspectors wroteBased on closed record review, review of a facility fall investigation, interviews and review of the facility policies, the facility failed to ensure adequate, individualized and effective fall risk interventions were in place to prevent a fall with injury for Resident #60, a resident at risk for falls. This affected one resident (#60) of three residents reviewed for falls. The facility census was 51. Actual Harm occurred on 03/10/25 when Resident #60 sustained an unwitnessed fall out of bed resulting in a fractured left arm, a laceration to the right side of her forehead, and a bruise to her right cheek. Prior to the incident, the resident had been having behaviors which staff identified as terminal agitation. [...]

Inspectors wroteBased on review of the medical record, review of the call light audit reports, and interview with the staff the facility failed to answer call lights timely for Resident #10 and #58. This affected two residents (Resident #10 and #58) of three residents reviewed for call light response times. The facility census was 57.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure foods were labeled, dated, and discarded when expired. This had the potential to affect all 51 residents in the facility. Findings Include: Observation of the main kitchen and resident refrigerators on 03/10/24 starting at 8:59 A.M. with Dietary Manager (DM) #235 revealed the following areas of concern: • In the dry storage area in the main kitchen, there was an expired case of tortillas dated December 2023. • In the juice and supplement cooler in the main kitchen, there were multiple containers of yogurt and juice that were out of date. • On the Division One unit, there were two containers of takeout food without a date or name. • On the Rehab unit, there was takeout with Resident #26's name and a date of 02/22/24. [...]

Inspectors wroteBased on interview and record review the facility failed to initiate care plans for hospice care and medication monitoring. This affected six residents (#7, #14, #17, #23, #37 and #39) out of 18 residents reviewed for care planning. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #17 revealed an admission date of 05/30/2023. Diagnoses included respiratory failure, chronic kidney disease, Multiple Sclerosis, and localized swelling. Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was cognitively intact, was dependent for mobility, and received anticoagulant medication. [...]

Inspectors wroteBased on interview, record review, and policy review the facility failed to monitor residents using anticoagulant medications. This affected three residents (#7, #17 and #23) out of seven residents reviewed for medications. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #17 revealed an admission date of 05/30/2023. Diagnoses included respiratory failure, chronic kidney disease, Multiple Sclerosis, and localized swelling. Review of Resident #17's admission Minimum Data Set assessment dated [DATE] revealed the resident was cognitively intact, was dependent for mobility, and received anticoagulant medication. Review of the Resident #17's March 2023 physician orders revealed an order dated 06/23/23 for Eliquis (anticoagulant or blood thinning medication) with directions to give 2.5 milligrams (mg) by mouth two times a day for blood clots. [...]

Inspectors wroteBased on observation, interview, record review, and policy reviewed the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) into Resident #36's Enhanced Barrier Precautions (EBP) room and completed appropriate hand washing during incontinence care for Resident #36. This affected one resident (#36) out of three residents reviewed for transmission-based precautions. This had the potential to affect all ten residents (#5, #20, #36, #7, #37, #4, #9, #1, #103, and #29) on the 500-hall where Resident #36 resided. The facility census was 51. Findings Include: Review of the medical record for Resident #36 revealed an admission date of 02/05/24. Diagnoses included hydronephrosis with renal and ureteral calculous obstruction, urinary tract infection, and Multiple Sclerosis. [...]

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure monitoring for medication effects and potential adverse consequences was completed for residents who were receiving psychotropic medications. This affected two residents (#37 and #39) out of five residents reviewed for unnecessary medications. The facility census was 51 residents. Findings Include: 1. Review of Resident #37's medical record revealed an admission date of 11/20/22 and diagnoses including hyperkalemia, obesity, moderate protein-calorie malnutrition, and cognitive communication deficit. Review of Resident #37's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had moderate cognitive impairment and received antianxiety and antidepressant medications. [...]

Inspectors wroteBased on interview, record review, and policy review the facility failed to obtain an ordered culture and sensitivity prior to starting antibiotic therapy for Resident #23. This affected one resident (#23) out of five residents reviewed for antibiotic stewardship. The facility census was 51. Findings Include: Review of the medical record for Resident #23 revealed an admission date of 09/18/20. Diagnoses include Parkinson's disease, fibromyalgia, and hypertension. Review of Resident #23's nursing note dated 12/12/23 at 9:46 A.M. revealed the physician saw the resident on rounds. The resident complained of constipation and abdominal discomfort due to constipation. The physician examined the resident's abdomen and bowel sounds. The resident complained of burning with urination. A urinalysis, lab, and antibiotic were ordered. [...]

Inspectors wroteBased on review of the infection control logs, review of facility policy and interviews with staff, the facility failed to maintain proper surveillance of all infections in the facility. This had the potential to affect all 51 residents in the facility.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure timely initiation of wound treatment orders and thorough admission skin assessments for Resident #7, #8, #10, and #13 and failed to ensure a weekly wound assessment was completed for Resident #1 who had existing wounds. This affected five residents ( Resident #1, #7, #8, #10 and #13) of 15 residents reviewed for wounds. The facility census was 51.

Inspectors wroteBased on a review of the medical record and interview with staff the facility to failed to ensure the resident representative for Resident #1 was notified of a new antibiotic treatment for a wound infection for Resident #1. This affected one resident (Resident #1) of 15 residents reviewed for change of condition. The facility census was 51.

Inspectors wroteBased on record review, review of facility policy and interviews, the facility did not ensure the Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property policy was implemented to ensure timely reporting of alleged resident mistreatment to the Administrator, timely reporting of the allegation to the Ohio Department of Health (ODH) and thorough investigation of the incident. This affected three residents (Resident #23, #32 and #41) of eleven residents reviewed for abuse. The facility census was 51.

Inspectors wroteBased on record review, review of facility policy and interviews, the facility did not ensure an allegation of resident mistreatment was immediately reported to the Administrator and was timely reported to the Ohio Department of Health (ODH). This affected one resident (Resident #23) of eleven residents reviewed for abuse. The facility census was 51.

Inspectors wroteBased on observation and interview, the facility failed to ensure the dishwasher was functioning in accordance with sanitation requirements. This had the potential to affected all 43 residents who consumed food or drink from the kitchen.

Inspectors wroteBased on medical record review and staff interview the facility failed to provide restorative nursing services for Resident #4, #14, and #33 per therapy recommendation and as care planned. This affected three residents (Resident #4, #14, and #33) of five reviewed for activities of daily living.

Inspectors wroteBased on interviews and record review, the facility failed to ensure showers were provided a minimum of twice a week for Resident #31 and #33, and nails were cleaned and trimmed for Resident # 14. This affected three residents (Resident #14, Resident #31, and Resident #33) of three residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on review of the medical record, facility Self-Reported Incident (SRI) review, staff interview, and Ohio Revised Code review, the facility failed to ensure the admissions coordinator had not signed a cognitively impaired resident's signature and initials on her Durable Power of Attorney for Healthcare. This affected one resident (Resident #242) of one reviewed for falsification of records.