St. Joseph's Rehabilitation and Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure 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. Findings are: A. Review of the facility policy Activities of Daily Living (ADL)'s, Services to Carry Out with a revision date of 7/2021 revealed the facility provided treatment and services to attain and maintain the highest practicable physical, mental, and psychological well-being of each resident in accordance with the plan of care. If residents were unable to carry out ADL's, the necessary services to maintain good nutrition, grooming, mobility, and personal oral hygiene was provided by qualified staff. The residents' needs were outlined in the plan of care. B. Review of Resident 3's Minimum Data Set (MDS-federally mandated assessment used to develop resident care plans) dated 12/23/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure 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. Findings are:Review of the facility Immunization policy with a revision date of 4/2025 revealed the facility offered and administered influenza, pneumococcal, and COVID-19 immunizations to eligible residents after providing education on the risks and potential side effects of the vaccines and obtaining consent. The purpose was to minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza, pneumococcal disease, or COVID-19 by ensuring that each resident was informed about the benefits and risks of immunization; and had the opportunity to receive those immunizations unless clinically contraindicated. Review of the facility admission Packet revealed a Resident Consent for Influenza, Pneumococcal and COVID-19 Form that was presented to residents and/or their responsible party at the time of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure 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. Findings are: A. Review of the Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -2-310.14 Food employees shall wash their hands and exposed portions of their arms immediately before engaging in food preparation: -after handling soiled equipment or utensils; and -during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. -3.304.15 (A) Single use gloves shall be used for only one task and should be discarded when soiled or when interruptions occur in the operation. B. During observation of the noon meal service on 12/12/24 at 12:00 PM to 12:40 PM, Dietary [NAME] (DC)-P with gloved hands placed piece of pork loin on the dinner…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure 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. Findings are: A. Review of the facility policy Fall Management System last reviewed 12/23 revealed the following: -Residents with high risk factors identified on the Fall Risk Evaluations would have an individualized care plan developed that included measurable objectives and timeframe's, -review of the incident would include an investigation to determine probable causal factors, -the investigation would be reviewed by the interdisciplinary team, -the Resident's care plan would be updated, and -the Quality Assurance Committee would analyze trends related to falls and would determine if further intervention was needed. B. Review of Resident 16's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure 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. Findings are: A. Review of the facility policy for Standard and Transmission-Based Precautions with a revision date of 3/2024 revealed the following: -It was the facility policy to implement infection control measures to prevent the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY License 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. Findings are: A. Review of the facility policy Immunizations-Residents with a revision date of 10/24 revealed the receipt of vaccinations was essential to the health and well-being of long-term care residents. Establishment of an immunization program against influenza and pneumococcal disease facilitated achievement of this objective. The following procedures were identified; -residents were to be screened at admission to determine vaccine status and eligibility using current Centers for Disease Control (CDC) guidelines, to receive influenza and pneumococcal vaccines and then annually for the influenza vaccine. -before offering the vaccine each resident and/or their representative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY License 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. Findings are: A. Review of the facility policy Immunizations-Residents with a revision date of 10/24 revealed the receipt of vaccinations was essential to the health and well-being of long-term care residents. Establishment of an immunization program against influenza and pneumococcal disease facilitated achievement of this objective. The following procedures were identified; -residents were to be screened at admission to determine vaccine status and eligibility using current Centers for Disease Control (CDC) guidelines, to receive COVID-19 vaccine. -before offering the vaccine each resident and/or their representative were to receive education regarding the benefits and potential side effects of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure 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. Findings are: A. Review of the facility Resident's Rights Policy with a revision date of 8/2007 revealed it was the policy of the facility to promptly notify the resident, his/her attending physician, and/or family/responsible party of changes in the resident's condition and/or status. The policy indicated the Charge Nurse was to notify the resident's attending physician when: -the resident had a significant change in the resident's physical, mental, or psychosocial status.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure 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. Findings are: A. Review of Resident 17's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 10/9/24 revealed the resident was admitted [DATE] with diagnoses of high blood pressure, heart failure, Alzheimer's disease, non-Alzheimer's dementia, depression and obstructive sleep apnea (sleep disorder characterized by repeated episodes of partial or complete blockage of the upper airway during sleep). The following was assessed for the resident: -cognition was severely impaired. -required partial…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure 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. Findings are: A. Review of the facility policy Antibiotic Stewardship, last reviewed 12/23 revealed the following: -the Antibiotic Stewardship Program (ASP) would promote appropriate use of antibiotics while optimizing treatment of infections while reducing possible adverse events, -require antibiotic orders to include the indication, dose, and duration, -the pharmacy consultant would review and report antibiotic usage on a monthly basis, and -education opportunities, repeated regularly, would be provided as appropriate to staff and/or family. B. Review of Resident 16's Minimum Data Set (MDS-a federally mandated assessment tool used in Care Planning) dated 10/23/24 revealed the resident had moderate cognitive impairment; required assistance with dressing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure 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. Findings are: A. Review of the facility policy Date Marking with a revision date of 6/20 revealed all food leftovers were to be labeled and dated to reflect the date the food was prepared. In addition, the leftovers were to be used within 3 days and if not used in this timeframe, discarded. B. During an observation on 11/20/23 at 9:10 AM the following unlabeled/ undated and/or outdated food items were stored in the walk-in refrigerator; -eleven Styrofoam containers covered with plastic lids which were undated and had no label; -pork in a broth which was dated 11/8/23; -squash dated 11/12/23;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure 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. Findings are: A. Review of the facility policy Resident's Rights and Dignity Regarding Nutrition with a reviewed date of 8/23 revealed the resident's rights and dignity were to be maintained by all staff. In addition, all residents at each table were to be served their meals at the same time. B. Observation of the facility dining room on 11/20/23 from 12:05 PM to 12:55 PM revealed the following: -Residents 4 and 22 were seated at the same table in the dining room for the noon meal. Resident 4…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure 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. Findings are: A. Review of the facility policy Hand Hygiene (use of alcohol-based hand sanitizer or washing with soap and water) with a revision date of 5/23, revealed hand hygiene was recognized as a primary method of decreasing health care associated infections and was a foundational component of infection prevention. Staff were to perform hand hygiene: -before touching a resident; -after contact with a contaminated surface; and -after touching a resident. B. Observation on 11/20/23 from 12:05 PM to 12:55 PM revealed the following for Residents 1, 9, 11, 13 and 35 who were seated at an assisted table in the dining room: -Resident 11 was served the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY C. 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: grip strips in front of the recliner, a sign on the resident's walker to remind the resident not to get up without assistance, and non-skid material to the front of the resident's recliner to prevent slipping out of the chair, and -on [DATE] per therapy the resident was independent in the resident room using a walker during the daytime only and required assist of 1 to walk to the dining room. Review of the facility incident report dated [DATE] revealed the following: -the resident had a fall on [DATE] at 3:08 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure 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. Findings are: Review of Resident 13's Nursing Progress Notes revealed the following: -9/27/23 at 1:00 PM the resident had choked at the noon meal. The resident's oxygen saturation level (amount of oxygen circulating in the blood. Normal levels are between 95-100 percent) was 87 percent and wheezes were heard. The resident was sent to the hospital for evaluation; -9/27/23 at 4:15 PM the resident was admitted to the hospital for aspiration pneumonia; and 10/11/23 at 4:25 PM the resident was admitted to the hospital with a diagnosis of pneumonia. During an interview on 11/27/23 at 3:33 PM the Administrator revealed notification of a resident's transfer and/or discharges to the hospital were to be sent on a monthly report to the Ombudsman by the Business Office Manager. However, there was no evidence…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY D. 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. Review of the facility form titled Non-Emergent Fax Transmission/Phone Orders dated 1/30/23 revealed Resident 39 received a new diagnosis of other specified schizophrenia spectrum and other psychotic disorder- audio and visual…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings are: Review of the facility policy titled Care Plan Timing and Revision, last approved 2/22 revealed the comprehensive care plan must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Review of Resident 19's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used in care planning) dated 10/4/23 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 9/14/23 revealed the following: -the resident required supervision to limited assistance with dressing, toileting, and hygiene, -the resident had a fall on 8/12/23 where the resident was sent to the ER, and -fall interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure 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. Findings are: A. Review of the facility policy Transfer and Discharge Including AMA (against medical advice) date 11/2023 revealed the following; For a community discharge, a discharge summary and plan of care should be prepared for the resident and documented in the medical record. -For anticipated discharge; members of the interdisciplinary team completed and included a recap of the resident's stay that included diagnosis, course of illness/treatment or therapy, pertinent lab, radiology and consultation reports, a final summary of the resident's status. Review of Resident 45's Minimum Data Set (MDS- federally mandated comprehensive assessment used in the development of resident Care Plans) dated 10/4/23 revealed the resident was admitted to the facility on [DATE] with limited assistance provided for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure 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. Findings are: A. Review of the facility policy Treatment Services to Prevent/Heal Pressure Ulcers dated 7/22 revealed the facility was to establish and utilize a systemic approach for pressure injury prevention and management, starting with a prompt assessment and treatment, including efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of interventions and modify the interventions as appropriate. The following interventions for prevention and to promote healing were identified: -interventions to be based on specific factors identified with risk, skin and any pressure injury assessments; -interventions to be implemented for all residents assessed at risk or who have a pressure injury present; -treatments to be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.