St. Joseph Residence

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 4 residents (R) (R57, R18, R40, and R3) of 16 sampled residents. Certified Nursing Assistant in Training (CNAT)-D entered the dining room and placed a ice pack from R57's room on R57's knee. R57 was on enhanced barrier precautions (EBP). Without completing hand hygiene, CNAT-D then passed lunch trays and put clothing protectors on R18, R40, and R57. R18 was on EBP. CNA-E did not don a gown or gloves prior to transferring R18 from recliner to wheelchair. R3 was on EBP. CNA-E emptied R3's catheter bag and removed personal protective equipment (PPE). CNA-E then removed garbage from a can, opened the door, and exited the room without completing hand hygiene.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure appropriate respiratory care and services were provided for 2 residents (R) (R18 and R28) of 2 sampled residents. R18 had a continuous positive airway ressure (CPAP) machine. R18 did not have an order to use the CPAP machine or orders to clean the face mask or tubing. R28 used a nebulizer machine. R28's nebulizer tubing was not changed according to the facility's policy. In addition, R28's medical record did not contain orders to change the nebulizer tubing or clean the face mask and other parts of the nebulizer.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the coordination of Hospice services for 1 resident (R) (R3) of 1 sampled resident. R3 received Hospice services. R3's medical record did not contain a current Hospice care plan and Certified Nursing Assistant (CNA) visit notes were not accessible. In addition, the facility did not coordinate or document bed baths and offer range of motion (ROM) exercises per R3's request.

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 residents (R) (R1 and R2) of 8 sampled residents. On 6/27/25, R1 and R2 were struck by Family Member (FM)-C) in the dining room. FM-C aggressively grabbed at R1, pulled R1 in, and hit R1 in the mid-section with a closed fist. FM-C also slapped R2 on the right hand, grabbed R2's left hand, and pulled R2's wheelchair toward FM-C. The facility did not notify local law enforcement of the abuse.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) in a timely manner for 1 resident (R) (R1) of 1 sampled resident. On 10/15/24, R1 reported an allegation of abuse that involved a Certified Nursing Assistant (CNA). The facility did not submit an initial or five-day report to the SA in a timely manner.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection as observed during the provision of care for 4 Residents (R) (R42, R31, R20, and R34) of 4 sampled residents. Staff did not wear a protective gown during wound care for R42. Staff did not wear the appropriate personal protective equipment (PPE) during an observation of high-contact care for R31 who was on enhanced barrier precautions (EBP). R20 had a history of methicillin-resistant Staphylococcus aureus (MRSA), a chronic wound, and a catheter. The facility did not place R20 on EBP. R34 had chronic bilateral leg wounds that required wound care by the facility. The facility did not place R34 on EBP.

Inspectors wroteBased on staff interview and record review, the facility did not notify the State Long Term Care Ombudsman of hospital transfers for 2 Residents (R) (R22 and R43) of 4 residents reviewed for hospitalization. R22 was transferred to the hospital on 5/13/24 and 7/13/24. The State Long Term Care Ombudsman was not provided with written notice of the transfers. R43 was transferred to the hospital on 7/10/24. The State Long Term Care Ombudsman was not provided with written notice of the transfer.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R20) of 1 sampled resident received the appropriate care and services to prevent urinary tract infections (UTIs). Staff did not ensure R20 received catheter care in a manner that decreased the risk of infection.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the correct amount of Jevity 1.2 (a nutritional meal supplement) was administered for 1 Resident (R) (R7) of 1 sampled resident. On 8/6/24, Surveyor observed Licensed Practical Nurse (LPN)-D administer one 237 mL (milliliter) container of Jevity 1.2 instead of the 250 mL that was ordered by the physician.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure an individualized comprehensive care plan was developed for 1 Resident (R) (R14) of 19 sampled residents. R14 did not have an individualized care plan that included activities to meet R14's interests and support R14's physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R29) of 2 residents reviewed for pressure injuries received care and treatment to prevent the development of pressure injuries. R29 was at risk for the development of pressure injuries. R29's plan of care contained an intervention for a cushion in R29's recliner. R29 was observed without a cushion in R29's recliner.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R17) of 5 sampled residents was monitored for adverse consequences for a high-risk medication. R17 was prescribed furosemide (a diuretic medication). R17's plan of care did not contain monitoring for adverse consequences of furosemide.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 Resident (R) (R17) of 5 sampled residents was monitored for adverse consequences of an antipsychotic medication. R17 was prescribed risperidone (an antipsychotic medication) for dementia. R17 did not have a care plan that addressed antipsychotic medication use and contained monitoring interventions for adverse consequences of the medication.