St. Joseph Skilled Nursing and Rehabilitation

Inspectors wroteBased on interviews and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment, and to help prevent the development and transmission of communicable diseases and infections as evidenced by: 1) failure to effectively decontaminate the environment of residents on contact isolation with confirmed or suspected C. Difficile infection and 2) failure to properly identify possible communicable diseases or infections before they spread. This deficient practice had the potential to affect 85 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for COVID-19 immunizations for 5 (#8, #20, #32, #92, & #106) of 5 residents reviewed for immunizations. The facility failed to ensure the residents' medical records included documentation that indicated the residents or resident representatives received education regarding the benefits and potential side effects of COVID-19 immunization. This deficient practice had the potential to affect 85 residents residing in facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assess residents for self-administration of medications for 2 (#46 & #109) of 2 sampled residents observed for medications available at the bedside.

Inspectors wroteBased on record review and interview, the facility failed to ensure the SNF ABN Form, CMS-10055 was provided to the resident and/or the resident's responsible party prior to the discontinuation of Medicare Part A services for 2 (#116, #117) of 3 residents reviewed for Beneficiary Notification who required the notification.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents were free of chemical restraints for 1 (#38) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the discharge notices were sent to the Office of the State Long-Term Care Ombudsman for 2 (#107, #108) of 2 residents sampled for discharges.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice by failing to clean and store piston syringes in accordance with facility policy for 1 (# 74) of 1 residents reviewed for enteral feedings.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure residents were assessed for the risk of entrapment from bedrails prior to installation for 2 (#53 and #77) of 3 residents identified for having side rails in use.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents were free from unnecessary medications for 1 (#38) of 5 residents sampled for medication review.

Inspectors wroteBased on record review and interview the facility failed to ensure grievances were investigated for 1 (#1) of 3 (#1, #2, #3) sampled residents. The facility failed to investigate a grievance by Resident #1's RP (responsible party) promptly.

Inspectors wroteBased on observations, interview and record review the facility failed to use infection control standards of practice for 1(#2) of 3 (#1, #2 and #3) sampled residents by not properly storing a resident's Foley catheter bag preventing an increased risk of contamination and infection. Resident #2's Foley catheter bag was improperly stored on the floor.

Inspectors wroteBased on record reviews and interview the facility failed to ensure nurses started a medication that had been ordered by the physician for 1(#2) of 3 (#1, #2 and #3) sampled residents. The facility failed to start the medication Naltrexone for resident #2.

Inspectors wroteBased on record reviews and interviews, the facility failed to: 1) ensure a resident was permitted return to the facility after hospitalization for 3 (#1, #2, #3) of 3 (#1, #2, #3) residents reviewed for transfer and discharge and; 2) have documentation a resident or resident's responsible party and the Ombudsman being notified in writing of the transfer/discharge and appeals right for 3 (#1, #2, #3) of 3 (#1, #2, #3) residents reviewed for transfer and discharge. Review of the facility's Transfer or Discharge, Facility-Initiated policy dated 2022 revealed the following in-part: Transfer and discharge includes movement of a resident from a certified bed in the facility to a non-certified bed in another part of the facility, or to a non-certified bed outside the facility. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. [...]

Inspectors wroteBased on record review and interview, the facility failed to have documentation a resident received information on resident rights and the temporary leave-bed hold policy for 1 (#2) of 3 (#1, #2, #3) residents reviewed for resident rights.

Inspectors wroteBased on observations, record review and interviews the facility failed to assess a resident for self-administration of medications for 1 (#323) of 1 sampled residents.

Inspectors wroteResident #62 Review of the medical record for resident #62 revealed an admission date of 06/14/2024 with diagnoses including encephalopathy, epilepsy, malignant neoplasm, protein calorie malnutrition, and dehydration. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed resident #62's Brief Interview for Mental Status (BIMS) score was 99 which indicated that the resident was unable to complete the interview. Resident #62 was dependent on staff for activities of daily living. Review of the current care plan revealed resident #62 required extensive assistance with eating. Further review of the care plan revealed interventions were to allow the resident adequate time to eat, monitor his food intake at each meal, and to document the meal percentage consumed. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good personal hygiene for 7 (#3, #16, #41, #45,#58, #62 and #221) of 11 (#3, #16, #37, #40, #41, #45, #58, #62, 221, #223, and #324) residents reviewed for Activities of Daily Living (ADL) care. The facility failed to ensure 1) residents' fingernails were kept clean and/or trimmed for #16, #41, #58 and #62, and 2) residents #3, #45 and #221 received baths as scheduled.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible by not completing an Accident/Incident report when a resident was found sitting on the floor for 1 (#62) of 3 (#51, #62, and #222) residents reviewed for falls.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide respiratory care consistent with professional standards of practice for 3 (#2, #323, and #325) of 3 (#2, #323, #325) residents sampled for respiratory care. The facility failed to ensure 1) Resident's oxygen concentrator filters were clean for (#2, #323) and 2) The resident's nebulizer equipment and tubing were dated and stored appropriately for (#323, #325).

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails and/or reviewed the risks and benefits of bed rails with the resident or resident's representative and/or obtain an informed consent prior to installation of bed rails for 5 (#9, #16, #31, #40, and #62) of 6 (#9, #16, #31, #40, #51, and #62) residents reviewed for accident hazards.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that each resident was free from unnecessary medication use for 5 (#3, #37, #43, #49, and #51) of 5 (#3, #37, #43, #49, and #51) residents sampled for unnecessary medication review. The physician/prescriber failed to provide a rationale for continuation of psychotropic medications.

Inspectors wroteBased on observations, record review and interviews the facility failed to securely store medications in a resident's room per the policy and procedure when self-administering medication for 1 (#323) of 1 (#323) residents self-administering medications.

Inspectors wroteBased on observation, policy review and interviews the facility failed to implement policies and procedures for enhanced barrier precautions (EBP) for 4 (#7, #45, #321, #322,) of 4 (#7, #45, #321, #322) residents reviewed for enhanced barrier precautions.

Inspectors wroteBased on record review and interview, the facility failed to retain the resident's personal possessions, including clothing, by not having a system in place to record residents' personal belongings. The facility failed to have an inventory record of the resident's personal belongings for 1 (#62) of 2 (#42 and #62) residents reviewed for personal property.

Inspectors wroteBased on observation and interview, the facility failed to ensure the most recent state inspection results since the last annual survey were available for resident or family review.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (#3) of 3 (#3, #62, and #222) residents reviewed for quality of life. The facility failed to transport resident #3 to her appointment in a timely manner to ensure she was seen by the physician.

Inspectors wroteBased on record review and interviews the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to obtain a hemoglobin A1C and lipid panel for 1 (#49) of 5 (#3, #37, #43, #49, #51) residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident admitted to the facility with a surgical wound was provided care and treatment to the wound for 1 (#4) of 5 (#1 - #5) sampled residents reviewed.

Inspectors wroteBased on record reviews and interviews the facility failed to protect the resident's right to be free from sexual abuse by a resident for 2 (#2 and #3) of 3 (#1, #2, #3) residents reviewed for abuse. The facility failed to protect Resident #2 and Resident #3 from inappropriate sexual advances by Resident #1.

Inspectors wroteBased on record reviews and interviews the facility failed to inform the resident's responsible party of a resident's change in condition for 2 (#5 and #6) of 4 (#4, #5, #6 and #7) records reviewed for resident rights. The facility failed to notify 1) resident #5's responsible party when she expired on [DATE], and 2) resident #6's responsible party when the facility had to reschedule 2 psychiatric appointments.

Inspectors wroteBased on record review and interviews the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene by, not having documented evidence that residents received baths as scheduled for 1 (#6) of 3 (#5, #6 and #7) records reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#6) of 3 (#4, #6 and #7) residents reviewed for limited range of motion.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The facility failed to ensure 1) resident #1 was administered medications per physician orders, and 2) the nurses documented the amount of sliding scale insulin administered to resident #2 in a total of 3 residents reviewed for medications.

Inspectors wroteBased on record review and interviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#74) of 2 (#74, #131) sampled residents reviewed for dignity. This deficient practice was evidenced by staff members calling resident #74 a name other than his legal name.

Inspectors wroteBased on observations and interview, the facility failed to ensure residents were informed of the type of care giver or professional that will be providing services. This deficient practice had the potential to affect 70 residents who resided in the facility as per the facility's Resident Census and Conditions of Residents Form.

Inspectors wroteBased on record review and interviews, the facility failed to conduct a comprehensive assessment which included the resident's dental assessment for 1 (#6) of 1 (#6) residents reviewed for dental care.

Inspectors wroteBased on record reviews and interviews, the facility failed to implement a comprehensive person centered plan of care to attain or maintain a resident's highest practicable physical well-being for 2 (#74, #131) of 4 (#60, #70, #74, #131) sampled residents reviewed for pressure ulcers. The facility failed to have evidence that the residents were turned and repositioned every 2 hours and received incontinent care as stated in the careplan for resident #74 and resident #131.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide assistance for residents who were unable to carry out activities of daily living (ADL) by failing to maintain good grooming and personal hygiene for 3 (#13, #36, and #281) of 7 (#13, #36, #45, #67, #74, #131, and #281) residents reviewed for activities of daily living.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (#35) of 1 resident reviewed for nonpressure related wound care and for 1 (#54) of 1 resident reviewed for positioning. The facility failed to provide wound care for resident #35 as ordered by the physician and failed to provide appropriate positioning while feeding resident #54.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure a resident receives care, consistent with professional standards of practice to prevent the development of pressure ulcers by failing to have evidence that the residents were turned and repositioned every 2 hours, and received incontinent care for 2 (#74, #131) of 4 (#60, #70, #74, #131) residents at risk for developing pressure ulcers.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that pain management was provided to a resident who requires such services, consistent with professional standards of practice and resident's preference by failing to administer pain medication for 1 (#281) of 2 (#17, #281) residents reviewed for pain management.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for a resident's needs by: 1.) nurses failing to respond to a resident's call light in a timely manner for 1 (#131) of 1 (#131) resident's call lights observed, and 2.) having a Licensed Practical Nurse change the Peripherally Inserted Central Catheter (PICC) line dressings instead of a Registered Nurse for 1 (#60) of 1 (#60) resident that had a PICC line.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure State Registry verifications were obtained prior to hire for 4 (S5Certified Nursing Assistant (CNA), S11CNA, S12CNA, S14CNA) and also failed to ensure they were obtained monthly for 5 (S5CNA, S6CNA, S11CNA, S12CNA, S14CNA) of 5 (S5CNA, S6CNA, S11CNA, S12CNA, S14CNA) personnel records reviewed.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs for 3 (#62, #70, and #74) of 6 (#6, #7, #22 #62, #70, and #74) sampled resident reviewed for unnecessary medications. The facility failed to follow parameters for the administration of a blood pressure medication for resident #62 and failed to monitor resident #70 and #74 for edema while receiving a diuretic.