St. Joseph Rehab & Nursing Care Center

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively impaired, required staff assistance to meet his/her daily care needs, and was known to be resistant during care, the Facility failed to ensure that Resident #1 was treated in a dignified and respectful manner. On 6/08/26, Certified Nurse Aide (CNA) #1 reported that while assisting CNA #2 to provide care to Resident #1, that in response to the residents' resistant behavior, who was combative and yelling at them to stop, that CNA #2 responded in an aggressive, rough and disrespectful manner, did not stop as requested and continued until completing his/her care. Findings Include: [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one Resident #6 was free from signifigant medication error, out of a total sample of 27 residents. Specifically, for Resident #6 the facility failed to ensure nursing scheduled intravenous (IV) cefazolin (antibiotic) every eight hours as recommended by Infectious Disease (ID) placing Resident #6 at risk for not having a consistent level of antibiotic in his/her blood stream.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the proper dish machine wash and final rinse temperatures were maintained at the appropriate temperatures to effectively clean and sanitize dishware and cutlery to prevent foodborne illness.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that services met professional standards of practice for one Resident (#120), out of 27 sampled Residents. Specifically, for Resident #120 the facility failed to ensure nursing dated and labelled tube feeding formula as required, nursing failed to stop a tube feeding as ordered, and nursing failed to ensure free water flushes were scheduled in accordance with the physician's order.

Inspectors wroteBased on observations, record review, and interview for two Residents (#78 and #85) out of four residents observed the facility failed to ensure it was free from a medication error rate of greater than 5%. When two out of four nurses observed made two errors out of 27 opportunities resulting in a medication error rate of 7.41%. Specifically, 1. For Resident #78 the facility failed to ensure Nurse #1 administered the correct vitamin B complex with C and folic acid. 2. For Resident #85 the facility failed to ensure Nurse #2 administer the correct dose of MiraLAX.

Inspectors wroteBased on observations, record review and interview, the facility failed to maintain a dignified existence for residents during mealtimes on two out of three units. Specifically, 1. Staff stood over residents while assisting with meals on two out of three units. 2. Staff referred to residents as feeders on one out of three units.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure medications were stored in accordance with professional standards of practice. Specifically, 1 Medication used for Residents #15 and #18 were left unsecured in the resident's room, 2 Medication carts were left unattended and opened 3. Keys to the medication cart were left on top of the cart and unattended, and 4. Medication was administered and left by the bedside of a resident.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed 1. Ensure food items were properly dated and stored in the main kitchen. 2. Ensure food items and food preparation equipment were not stored with chemicals.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure garbage and trash were disposed of properly. Specifically, the area around the two dumpsters had a large volume of various debris, garbage and trash.

Inspectors wroteBased on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment that prevents the development and transmission of communicable diseases and infections for five Residents (#89, #33, #84 , #15 and #217) out of a total sample of 31 Residents. The facility also failed to implement and follow Enhanced Barrier Precautions (EBP) and droplet precautions for residents who were positive for influenza. Specifically, 1. For Resident #89 and Resident #33, the facility failed to maintain infection control practices during a wound dressing change 2. For Resident #84 and Resident #15, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented in accordance with the infection prevention control program. 3. [...]

Inspectors wroteBased on observation, record review and interview the facility failed for 2 Residents (#15 and #44 ) out of a total sample of 31 residents, to ensure: 1. Resident #15 was equipped with a call bell that functioned for him/her and, 2. That Resident #44 had a Broda chair available for when he/she chose to get out of bed.

Inspectors wroteBased on record review and interviews, the facility failed to develop a skin impairment care plan for one Resident (#33) out of a total sample of 31 residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure care plans were reviewed with the interdisciplinary team (IDT) as required for one Resident (#69) out of a total sample of 31 residents. Specifically for Resident #69 the facility failed to review and revise the care plan related to the use of an air mattress.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure a physician's order was implemented for three Residents (#28, #101 and #69) out of a total sample of 31 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to: 1) provide assistance with incontinence care for two Residents (#60 and #33) and 2) provide assistance with meals for two Residents (#25 and #55) out of a total sample of 31 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure services consistent with professional standards were provided for one Resident (#75) who required dialysis (a procedure to remove waste products and excess fluid from the body when the kidneys stop working properly), out of total sample of 31 residents. Specifically, the facility failed to follow physician's orders to ensure that blood pressure readings were not taken on the arm where the dialysis shunt (an access point from the dialysis machine to a blood artery) is located.

Inspectors wroteBased on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 2 out of 2 eligible sampled CNAs.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure accurate medical records were completed for three Residents (#28, #101 and #33) out of a total sample of 31 residents. Specifically, 1) for Residents #28 and #101 the facility failed to ensure physician orders were documented accurately and 2) for Resident #33 skin assessments were completed accurately.

Inspectors wroteBased records reviewed and interviews for one of three sampled residents (Resident #1), whose admission physician's orders included the administration of Eliquis (anticoagulant ), the Facility failed to ensure that upon completion of his/her admission Medication Regimen Review (MRR) by the Consultant Pharmacist that nursing reviewed and addressed the pharmacy recommendation related to his/her dosage of Eliquis timely, as a result for more than a month, Resident #1 was overmedicated with Eliquis, he/she experienced an acute change in medical status due to being administered excess Eliquis, and required hospital transfer with admission, where he/she received blood transfusions and additional treatments to stabilize his/her condition. Findings Include: [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sample residents (Resident #1), whose Hospital Discharge Summary indicated that the daily dosage of his/her Eliquis (anticoagulant) was to be decreased from 10 milligrams (mg) two times a day, to 5 mg two times a day, the facility failed to ensure Resident #1 was free from a significant medication error when due to a medication reconciliation error upon admission by nursing, he/she continued to be administered Eliquis 10 mg two times a day for more than a month after his/her admission. Resident #1 experienced an acute change in medical status which include shortness of breath, weakness and critically low blood laboratory work related to being overmedicated with Eliquis, he/she was transferred and admitted to the Hospital where he/she required blood transfusions and additional treatment in order to stabilize his/her condition.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to prevent a decline in range of motion causing the development of a contracture for one Resident (#78) out of a total sample of 33 residents.

Inspectors wroteBased on record reviews, policy reviews and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for two Residents (#36 and #96) out of a total sample of 33 residents. Specifically, 1) the facility failed to provide non-pharmacological interventions or behavioral health services for Resident #36 as he/she had increasing behaviors and psychological distress leading to two involuntary hospitalizations for psychiatric concerns and 2) the facility failed to provide behavioral health services for Resident #96 after he/she displayed increased depressive symptoms.

Inspectors wroteBased on observation policy review, and interview, the facility failed to 1). maintain a homelike environment on 3 of 3 resident units and 2) failed to provide a clean, sanitary, and homelike environment for one Resident (#91) out of a total sample of 33 residents. Specifically, for Resident #91, there was a brown liquid on multiple surface areas of the Resident's room that failed to be cleaned for three days.

Inspectors wroteBased on record review and interview, the facility failed to investigate six allegations of possible abuse, neglect and possible misappropriation evidenced by staff completing grievance forms instead of completing a full investigation.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide the necessary activities of daily living (ADLs) for dependent residents for four Residents (#9, #92, #66, #413) out of a total sample of 33 residents. Specifically, 1). the facility failed to provide the proper assistance with meals for three Residents (#9, #92, #66) and 2). the facility failed to provide nail care for Resident #413. Review of the facility policy titled ADL Support Guideline, dated 8/10/17, indicated the following: *Residents will provided [sic] with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming and personal and oral hygiene. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe environment for four Residents (#103, #43 #36, and #8) out of a total sample of 33 residents. Specifically: 1) For Resident #103 the facility failed to implement the physician's order for the use of fall mats. 2) For Resident #43 the facility failed to ensure nursing staff implemented the falls plan of care of having fall mats in place. 3) For Resident #36, a Resident who is at risk of elopement, the facility failed to provide the Resident with a wander guard (a device that would alarm if a resident were to leave the unit) as ordered. 4)For Resident #8, the facility failed to implement the physician's order for the use of bilateral bed siderail padding for a Resident with a history of epilepsy (a disorder of the brain characterized by repeated seizures).

Inspectors wroteBased on record review, observation and interview, the facility failed to provide care and services consistent with professional standards for four Residents (#51, #96, #69, #86) who required renal dialysis (a life sustaining treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) out of a total sample of 33 Residents. Specifically: 1) For Resident #51 the facility failed to ensure that nursing staff obtained a physician's order for dialysis and failed to ensure a care plan was developed for dialysis. 2) For Resident #96, the facility failed to implement recommendations from the dialysis center to hold his/her scheduled medications due to low phosphate. [...]

Inspectors wroteBased on observations, policy review, record review, and interviews for two Residents (#9 and #59) out of three Residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5% when two of two nurses observed made three errors out of 26 opportunities resulting in a medication error rate of 11.54%. Specifically, 1.) For Resident #9, Nurse #3 administered a medication ordered to be given with meals, without a meal. 2.) For Resident #59, Nurse #4 failed to administer scheduled eye drops as ordered and documented a medication (vitamin d) as administered when it was not.

Inspectors wroteBased on observation and interview the facility failed to properly store food items and properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain accurate medical records for two Residents (#8, #91) out of a total sample of 33 residents. Specifically: 1. For Resident #8, the facility documented that the Resident's bed side rails were padded when they were not, 2. For Resident #91, the facility incorrectly entered a physicians order for tube feeding, and 3. For Resident #91, the facility incorrectly documented a medication that was administered by a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication) was administered by mouth. 1. Resident #8 was admitted to the facility in June 2020 with diagnoses including history of epilepsy and anxiety disorder. [...]

Inspectors wroteBased on record reviews, policy review, and interviews, the facility failed to assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for three Residents (#20, #58 and #71) out of a total of 5 sampled Residents.

Inspectors wroteBased on record review, policy review and interview the facility 1) failed to allow one Resident (#36) the right to participate in his/her own treatment by having the Resident's Health Care Proxy (HCP) make the decision without the HCP being invoked by the physician and 2) failed to ensure informed consent for the administration of psychotropic medications, including the risk/benefits of the medication and potential side effects, was obtained from the resident and/or representative for one Resident (#19) out of a total sample of 33 residents.

Inspectors wroteBased on record reviews, observations and interviews the facility 1) failed to develop a care plan for suicidal and homicidal ideation for one Resident (#36) when he/she returned from an involuntary hospitalization, and 2) failed to develop a plan of care addressing a primary diagnosis of fluid overload and a fluid restriction for one Resident (#86), out of a total sample of 33 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to revise care plans for two Residents (#77, #86), out of a total sample of 33 residents. Specifically, 1. the facility failed to revise Resident #77's care plan related to skin impairment and 2. the facility failed to revise the hemodialysis (process by which dissolved substances are removed from a patient's body by diffusion from one fluid compartment to another across a semipermeable membrane) care plan for Resident #86 to accurately depict his/her dialysis access site.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an activities program to meet the needs of one Resident (#9) out of a total sample of 33 residents.

Inspectors wroteBased on observations, policy review, interviews, and records reviewed for two Residents (#104 and #20), out of 33 total sampled residents, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to 1.) obtain a physician order to treat a wound for Resident #104 and 2.) follow physician's orders to ensure safe positioning during meals for Resident #20.

Inspectors wroteBased on record review and interview, the facility failed to implement treatment recommendations related to pressure ulcers for one Resident (#9) out of a total of 33 sampled Residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain acceptable parameters of nutritional status for 1 Resident (#86) out of a total sample of 33 residents. Specifically, the facility failed to maintain a 1,000 milliliter (ml) fluid restriction per the physician's orders for Resident #86.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to ensure staff provided appropriate care and services for one Resident (#91) with a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 33 sampled residents. Specifically, the facility failed to follow physician orders for accurate rate of administration of tube feeding for Resident #91.

Inspectors wroteBased on observations, policy review, interviews, and records reviewed the facility failed to provide respiratory care services in accordance with professional standards of practice for two Residents (#88 and #86), out of a total of 33 sampled residents. Specifically, the facility failed to 1. follow physician's orders for oxygen management and change oxygen tubing that was left on floor for one Resident (#88) and 2. Ensure that oxygen was administered per physician's orders for one Resident (#86).

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that the bed rail was implemented in accordance with the bed rail assessment, and that a physician's order was obtained for the use of the bed rail, for one Resident (#77)out of a total sample of 33 residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide medically-related social services to attain or maintain the highest practicable mental and psychosocial well-being for one Resident (#36) out of a total sample of 33 residents. Specifically, the facility social workers failed to provide support and non-pharmacological interventions to Resident #36 as he/she had increasing behaviors and psychological distress leading to two involuntary hospitalizations for psychiatric concerns.

Inspectors wroteBased on record review and interview the facility failed to ensure that recommendations made by the consulting pharmacist during the monthly medication review were acted on by the physician for one Resident (#103), out a total sample of 33 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a PRN (as needed) psychotropic medication was re-evaluated and included a duration of use for one Resident (#19) out of a total sample of 33 residents.

Inspectors wroteBased on observations, policy review, and interviews the facility failed to 1.) ensure medication carts were locked when unattended on one out of three nursing units, 2.) ensure medications carts were kept clean and orderly in one of four medication carts observed 3.) ensure that medications were properly labeled after opening on 3 of 5 medication carts observed 4.) ensure medications were not stored at bedside for a resident who is not assessed to self- administer medications.