St. Joseph's Rehabilitation and Care Center

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18Based on observation, interview, and record review; the facility failed to ensure infection control measures including the use of Enhanced Barrier Precautions (EBP-targeted use of Personal Protective Equipment (PPE-use of protective wear such as gown, gloves, and eye shields) during the provision of care to prevent potential transmission of Multi-Drug Resistant Organisms (MDRO's- germ/pathogen that has developed resistance to multiple classes of antimicrobials [antibiotics or antifungals]) was implemented for Resident's 2, and 3, and infection control measures to prevent potential infections during wound care were followed for Residents 2 and 4. The sample size was 4 and the facility census was 63.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to submit an investigation related to the unexpected death of Resident 1 to the State Agency within the required time frames. The sample size was 4 and the facility census was 56.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11 (E)Based on observation, record review, and interview; the facility failed to ensure food safety through safe food holding temperatures and evidence of dishwasher temperature checks for adequate sanitation. This practice had the potential to affect all residents. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 1-005.06CBased on record review and interview; the facility failed to have evidence of an active Antibiotic Stewardship Program this had the potential to effect all residents. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.06B Based on record review and interviews; the facility failed to address repeat grievances, and to ensure sustainable resolutions of concerns related to long call light response times and cold food temperatures. The total sample size was 26 and the facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(J)(i)Based on observation, interview and record review; the facility failed to ensure food was served at palatable (pleasant to taste) temperatures. The total sample size was 26 and the facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 006.18(B)(D)Based on observations, interviews and record review; the facility failed to perform hand hygiene at appropriate intervals during the provision of care and medication provision, failed to ensure proper use of Personal Protective Equipment (PPE-equipment such as gowns and gloves used by health care workers to minimize exposure to potential hazards including infectious materials, blood-borne pathogens and/or hazardous substances to create a barrier to reduce transmission between patients/residents) for Residents 2, 9, 39, and 41, and failed to implement Enhanced Barrier Precaution (EBP-targeted use of PPE during high-contact care provision for those resident identified as being at high risk for acquiring or transmitting Multi-Drug-Resistant Organisms (MDRO's-bacteria or germs resistant to major classes of antibiotic (often known as super-bugs) [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B)Based on interview and record review; the facility failed to ensure the Minimum Data Sets (MDS-federally mandated assessment used to develop resident care plans) were coded accurately regarding Resident 8's Preadmission Screening and Resident Review (PASRR-federally mandated screening completed prior to Nursing Facility admission, to determine if residents had Major Mental Illness (MMI), Intellectual Disability (ID) or a Related Disorder (RD) to determine appropriate placement or the need for special services) and Resident 2's Major Mental Illness Diagnoses. The sample size was 30 and the facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B)Licensure Reference Number 175 NAC 12-006.09(E) Based on interview and record review; the facility failed to ensure Resident 2's Preadmission Screening and Resident Review (PASRR-federally mandated screening completed prior to Nursing Facility admission, to determine if residents had Major Mental Illness (MMI), Intellectual Disability (ID) or a Related Disorder (RD) to determine appropriate placement or the need for special services) level 1 was completed accurately and failed to care plan Resident 25's PASRR results related to MMI. The sample size was 3 and the facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on observation, interview, and record review; the facility failed to provide routine hygiene (shaving) for Resident's 3, 10, and 14. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(J)(i)1Based on record review and interview; the facility failed to prevent weight loss for 1 (Resident 67) of 3 sampled residents. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(G)Based on observation, interview, and record review; the facility failed to have sufficient staff to meet the hygiene needs of Residents 3, 10, and 14 and to ensure timely call light response. This had the potential to affect all facility residents. The facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18(A)Based on record review and interview; the facility failed to provide Resident 8 with the pneumococcal vaccine that was consented to at the time of admission. The sample size was 5 and the facility census was 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(G)(i)Based on interview and record review; the facility failed to complete Ombudsman notifications and/or comprehensive discharge summaries for Residents 71, 72, and 74.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observation, interview and record review; the facility staff failed to wash hands and to change gloves to prevent the potential for cross contamination during the provision of a meal service. The facility census was 44 with a total sample size of 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(l) Based on observations, record review, and interview; the facility failed to review, revise, and/or implement care plan interventions to prevent falls for Residents 16, 19, and 7. The sample size was 5 and the facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observation, record review, and interview the facility failed to complete hand hygiene at appropriate intervals to prevent the potential spread in infection for Residents 17, 11, and 7, failed to utilize the appropriate Personal Protective Equipment (PPE-the use of protective clothing such as gowns, gloves, or other measures such as face/eye protection used to prevent the spread of infection and or protect care-givers during care) during the provision of care for Residents 34 and 7 who were on Enhanced Barrier Precaution (EBP-infection prevention through expanded use of PPE), and failed to develop and implement measures to prevent the growth of potential water borne illness. The sample size was 21 and the facility census was 44.

Inspectors wroteLicense Reference Number: 175 NAC 12-006.18(A) Based on record review and interviews; the facility failed to ensure 3 (Residents 31, 197 and 244) of 5 sampled residents were offered the Pneumococcal and the Influenza vaccines and/or were educated about the risks and benefits associated with the vaccines. The facility census was 44.

Inspectors wroteLicense Reference Number: 175 NAC 12-006.18(A) Based on record review and interviews; the facility failed to provide evidence 3 (Residents 31, 197 and 244) of 5 sampled residents were offered the COVID-19 vaccine and/or were educated about the risks and benefits associated with the vaccines. The facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i)5 Based on interview and record review; the facility failed to notify the Primary Care Physician (PCP) when Resident 17 did not receive an ordered medication, a Continuous Positive Airway Pressure (CPAP- a medical treatment that uses a machine to deliver air pressure to keep breathing airways open while sleeping) machine was available and a treatment was provided as ordered. In addition, the PCP for Resident 22 was not notified of a failure to administer an ordered medication which led to a hospitalization. The sample size was 2 and the facility census was 44.

Inspectors wroteLicensure Reference Number: 175 NAC 12-006.09 Based on interview and record review; the facility failed to follow practitioner's orders for Resident 17 related to administration of medications, use of a Continuous Positive Airway Pressure (CPAP- a medical treatment that uses a machine to deliver air pressure to keep breathing airways open while sleeping) machine and treatment orders and Resident 22 regarding medications. The sample size was 2 and the facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview; the facility failed to ensure Residents 16 and 19 had a documented duration of use for the long-term use of antibiotics. The sample size was 2 and the facility census was 44.

Inspectors wroteLicensure reference: 175 NAC 12-006.11E Based on observation, interview, and record review; the facility failed to ensure floors, vents, and equipment were maintained in a clean manner and in good repair, and left over foods were labeled and dated with the date of preparation and were discarded when food items were outdated to prevent the potential for food-borne illness. The facility census was 46 and this has the potential to affect all 46 residents who were served meals out of the kitchen.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(21) Based on observation, interview, and record review; the facility failed to promote resident dignity as staff: 1.) failed to serve each resident seated at the same table before serving the other residents in the dining room (this affected Residents 4, 22, 146, 3, 5 and 33); 2.) stood over residents while assisting with dietary intake (this affected Residents 1, 9, 11, 13 and 35); and 3.) utilized disposable dishware throughout the dining room for residents. The facility identified a census of 46 and 38 residents received meals in the dining room.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review; facility staff failed to perform hand hygiene at appropriate intervals between resident contacts when assisting with dietary intake. This had the potential to affect all residents (Residents 1, 9, 11, 13 and 35) who were seated at an assisted table. The facility identified a census of 46 and 38 residents were served meals in the dining room.

Inspectors wroteC. Review of Resident 19's MDS dated [DATE], revealed the following: -the resident had severe cognitive impairment, -had diagnoses of dementia and anxiety, -had 1 fall with an injury, and -received antianxiety medications. Review of Resident 19's Care Plan last reviewed on [DATE] revealed the following: -the resident required supervision to limited assistance with dressing, toileting, and hygiene, -the resident had a fall on [DATE] where the resident was sent to the ER, and -fall interventions included: [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 Based on record review and interview; the facility failed to notify the Ombudsman of discharges to the hospital (a state appointed advocate for residents of nursing homes) of 1 (Resident 13) out of 2 sampled residents. The facility census was 46.

Inspectors wroteD. Review of Resident 39's admission MDS dated [DATE] and a Quarterly MDS dated [DATE] revealed the following: -the resident had not been evaluated by Level II PASARR, -the resident was not marked to have a serious mental illness, -the resident had diagnoses of Dementia, Anxiety Disorder, Depression and Psychotic Disorder, -the resident had moderate cognitive impairment, and -received antipsychotic, antianxiety, and antidepressants. Review of Resident 39's PASSAR screen completed on 1/23/23 revealed the resident had no signs of a serious mental illness and no mental health diagnosis was suspected or known. Review of Resident 39's Order Summary revealed the resident had an order for Risperdal for a diagnosis of other psychotic disorder not due to a substance or know physiological condition. [...]

Inspectors wroteBased on record review, observations, and interview; the facility failed to revise 1 resident's (Resident 19) Care Plan to reflect current fall interventions. The facility census was 46 and the sample size was 1.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C3 Based on record review and interview; the facility failed to complete a discharge summary for 1 (Resident 45) of 2 sampled residents. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility failed to implement interventions to promote healing of a pressure ulcer for 1 (Resident 13) of 1 sampled resident. The facility census was 46.