Saint Joseph Transitional Rehabilitation Center

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the care planning process included feedback and information from a resident for 1 of 32 sampled residents (Resident 5). The deficient practice had the potential to result in care which did not reflect the resident's preferences, goals, and choices, diminishing the resident autonomy and person-centered care.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a significant change in status Minimum Data Set (MDS) assessment was completed within the required time frame for 1 of 32 sampled residents (Resident 50). The deficient practice had the potential to delay the development and implementation of a person-centered care plan for residents.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed within the required time frame for 3 of 32 sampled residents (Resident 21, 50, and 58). The deficient practice had the potential to delay the development and implementation of a person-centered care plan for the residents.

Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure comprehensive, resident-centered care plans were developed and implemented for ventilator use and tracheostomy care for 3 of 32 sampled residents (Residents 1, 4, and 10). The deficient practice had the potential to result in unmet respiratory care needs, inadequate staff direction, and compromised resident safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a comprehensive person-centered care plan after a new skin condition was identified for 1 of 32 sampled residents (Resident 89). The deficient practice had the potential to place the resident at risk for delayed treatment, infection, and discomfort.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a resident was assisted with meals in accordance with the assessment and care plan for 1 of 32 residents (R111). The deficient practice had the potential for residents not to maintain good nutrition.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure treatment was provided for a resident with an identified skin condition for 1 of 32 sampled residents (Resident 89). The deficient practice had the potential to place the resident at risk for delayed healing, worsening of the skin condition, and infection.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure wound care treatments were implemented as ordered for 1 of 32 sampled residents (Resident 1). The deficient practice had the potential to result in delayed healing, infection, and other negative outcomes for a resident with identified wound care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all required sections of the Provider Order for Life-Sustaining Treatment (POLST) form were completed for 4 of 32 residents (Resident 5, 50, 74, and 89), and failed to ensure resident's Power of Attorney (POA) documentation was present in the medical record for 3 of 32 sampled residents (Resident 1, 4, and 5). The deficient practice had the potential to result in the resident's treatment preferences and decision-making authority not being known or honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Water Management Plan was completed and implemented.

Inspectors wroteBased on interview, record review, and document review, the facility failed to consistently provide residents with a quarterly trust account statement for 1 of 19 sampled residents (Resident 72) and 2 unsampled residents (Residents 30 and 31). The deficient practice caused residents to lack peace of mind about their trust account balances.

Inspectors wroteBased on interview, record review, and document review, the facility failed to respond to each resident's grievance about their trust account statements for 1 of 19 sampled residents (Resident 72) and 2 unsampled residents (Residents 30 and 31). The deficient practice caused residents to feel slighted, angry, or suspicious of financial mismanagement by the facility.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure restorative nursing services were provided as ordered and scheduled for 1 of 19 sampled residents (Resident 16). The deficient practice had the potential for the resident's further decline in mobility and physical functioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician ordered medications were available for 2 of 19 sampled residents (Resident 72 and 16) and one unsampled resident (Resident 29). The deficient practice had the potential for the residents to have adverse events.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater for 1 of 19 sampled residents (Resident 16). Failure to administer medications as prescribed could have delayed the therapeutic treatment for the resident.

Inspectors wroteBased on observation and interview, the facility failed to ensure raw chicken stored inside the walk-in refrigerator was labeled with the date and time the chicken had been placed in the refrigerator. The deficient practice had the potential to allow bacteria to proliferate in raw poultry, a high-risk food.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure: 1) food items were labeled and not expired in 3 of 4 nourishment refrigerators, and 2) 1 of the 4 nourishment refrigerators was within the recommended temperature to keep cold foods cold. The deficient practice had the potential to impact the well-being of the residents through potential consumption of hazardous food items and breaches in infection control. 1) On 09/20/2023 in the morning, three of the four nourishment refrigerators contained both unlabeled and/or expired food items. One refrigerator located in the 100 unit contained the following unlabeled and/or expired food items: [...]

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure food preferences for a resident was followed for 1 of 23 sampled residents (Resident 74). The deficient practice prevented a resident to exercise the right of choice.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure residents restraints needs were assessed and evaluated; and nurses document the resident's need to have restraints for 1 of 23 sampled residents (Resident 34). The deficient practice prevented a resident's quality of life free from any restraint device.

Inspectors wroteResident 2 (R2) was readmitted on [DATE], with diagnoses including schizophrenia and right sided hemiplegia. Physician orders included nothing by mouth, and enteral feeding via a gastrostomy tube. The 06/23/2023 Quarterly MDS indicated the resident was unable to speak, had severe cognitive impairment, and was totally dependent in activities of daily living including requiring two person assist for hygiene and bathing. The MDS indicated the resident was incontinent of bowel and bladder. The current care plan indicated the resident needed assist with ADLs, was resistive to care due to traumatic brain injury, risk for dehydration, and incontinence. 09/21/2023 12:20 PM The resident was non-verbal but smiled in response to questions. [...]

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure a resident's pain levels were assessed and documented for 1 of 23 sampled residents (Resident 74). The deficient practice prevented the resident to be monitored for the effectiveness of pain management regimen.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure monitoring for the side effects of an anti-anxiety medication was completed for 1 of 23 sampled residents (Resident 4). The deficient practice had a potential for a resident not being monitored for side effects of psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of five percent (%) or greater for one unsampled resident (Resident 46). The deficient practice had the potential to delay the therapeutic treatment for the resident.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure an unopened vial of insulin was stored in accordance with the label of the medication and facility's policy for 1 of 3 medication carts inspected (Medication Cart 2 in 300 Hall). The deficient practice had the potential for the facility failing to maintain the efficacy of the medication.