St. Joseph's Hospital

Inspectors wroteBased on record review and staff interview, the facility failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days, unless the prescribing practitioner documented a rationale to extend the medication and indicated a duration for the PRN order. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifiers: #3 and #13. Facility Census: 15.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure observed medication rates were less than five (5) percent. During the medication administration facility task, three (3) errors were observed in 32 medication opportunities to equal an error rate of 9.23 percent. Resident Identifiers: #14 and #15. Facility Census: 15.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to store and label medications according to accepted standards of practice. A multi-use insulin pen located in the medication room refrigerator had not been dated when first accessed. This was found during the investigation for the medication storage and labeling facility task. Resident Identifier: #11. Facility Census: 15.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the nurse staff posting was accurate and reflected the correct number of hours worked by direct care staff. This failed practice has the potential to affect more than an isolated number of Residents. Facility Census: 15. a) Staff Posting On the afternoon of 07/06/26 the nurse staff postings for the previous two (2) weeks was requested. The following morning the postings were received and reviewed. This reviewed revealed on 06/27/26 there was not a night shift nurse listed on the posting. During an Interview with the Director of Nursing (DON) on the afternoon of 07/07/26 she confirmed the staff posting was wrong. She stated, Licensed Practical Nurse (LPN) #1 came in and covered night shift and was not added to the staff posting as required.

Inspectors wroteBased on Resident Council interview, staff interview and policy review, the facility failed to ensure forms were readily available to residents to file grievances. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 15.

Inspectors wroteBased on record review and staff interview the facility failed to develop person centered care plans related to activities. This failed practice was found true for (4) four of (5) five residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #9, #5, #8, and #12. Facility census: 15.

Inspectors wroteBased on Resident Council interview, record review and staff interview the facility failed to provide a program of activities to meet the needs and interests of the residents that included holiday themed and weekend activities. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility census: 15.

Inspectors wroteBased on observation, and staff interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Facility census: 15. : Findings Include: a) Dining observation An observation of the lunch meal service starting at 03/19/25 at 12:20 PM, revealed the first tray being served off the tray cart. Seven (7) residents were served in the dining room. The State Agency (SA) walked to the other end of the dining room and then walked back to the tray cart and (2) two dirty trays had been put on the meal cart with the (4) four remaining clean meal trays for the residents. During an interview, on 03/19/25 at 12:40 PM, Nurse Aide (NA) #15 stated, No we don't normally do that. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a safe environment in the communal shower room. This was a random opportunity for discovery. Facility census: 15.

Inspectors wroteBased on record review, and staff interview the facility failed to recognize, evaluate, and address Resident # 12's impaired nutrition and weight loss. This failed practice was found true for (1) one of (1) one resident reviewed for nutrition during the Long-Term Care Survey Process. Resident identifier #12. Facility Census 15.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure infection control standards were followed for a resident on enhanced barrier precautions (EBP). This was true for one (1) of one (1) residents observed for EBP's during the survey process. Resident identifier: #15. Facility census: 15.

Inspectors wroteBased on observation and staff interview the facility failed to provide dignity for Resident #8 during care. A glucose check was obtained without providing privacy. This failed practice was a random opportunity for discovery. Resident identifier: #8. Facility census: 15.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the resident's Pre admission Screening and Resident Review (PASARR) reflected pre-admission diagnoses for one (1) of one (1) residents reviewed for the category of PASARR. Resident #10 had a diagnosis of Bipolar Disorder on admission The lack of pre-screening resulted in the resident's condition not being evaluated through the Level II PASRR process. Resident identifier #10. Census 15. Findings Include: a) Resident #10 During a record review on 04/22/24 at 3:50 PM, Resident #10's medical record revealed a diagnosis of bipolar disorder dated 03/13/23. Further review of the medical record revealed a PASARR dated 11/09/23, Section 30 titled Current Diagnosis, was not coded k. Affective Bipolar Disorder. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure each resident received care in a manner which promoted their highest practicable physical, mental and psychosocial well being. The facility failed to provide Resident #8 with a comprehensive assessment by a Registered Dietician. This was a random opportunity for discovery. This is true for one (1) resident reviewed for the Long-Term Care Survey Process. Resident Identifiers: Resident #08. Facility Census: 15 Findings Include: a) Resident #8 During a medical record review on 04/22/24 at 2:30 PM, it was identified Resident #8 did not have a comprehensive assessment completed by a Registered Dietician. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to store food in accordance with professional standards for food service safety. The facility failed to monitor temperatures for an ice cream freezer. This failed practice had the potential to affect a limited number of residents. Facility Census: 15. Findings Include: a) Ice Cream Freezer During the initial tour of the kitchen with the Nutrition Services Supervisor beginning on 04/22/24 at 11:52 AM, an observation was made of the ice cream cooler. There was no documentation that the temperature of the ice cream freezer was monitored. An Immediate interview the Nutrition Services Supervisor acknowledged the temperatures were not being recorded for the ice cream freezer. She stated we never have monitored the ice cream freezer. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure a complete and accurate medical record. The facility failed to ensure the Physician Orders for Scope of Treatment (POST) form was completed per directions specified by the [NAME] Virginia Center for End of Life Care. This is true for one (1) of 15 residents reviewed for the Long-Term Care Survey Process. Resident Identifiers: Resident #08. Facility Census: 15 Findings Include: a) Resident #8 During a medical record review on 04/23/24 at 10:30 AM, Resident #8's medical record revealed a Physician Orders for Scope of Treatment (POST) form which failed to include the date the Medical Power of Attorney (MPOA) for Resident #08 and facility Social Worker (SW) #18 signed and completed the POST form. On 04/23/24 at approximately 10:45 AM, during a reivew of the 2021 POST form guidance titled, Using the POST Form: [...]