Mount Saint Joseph Rehab Center

Based on record review and staff interview, the facility failed to ensure its arbitration agreement contained all necessary information. This had the potential to affect all residents. The facility census was 82. Findings include: Review of the facilities arbitration agreement revealed the agreement did not address the selection of a neutral arbitrator for the arbitration proceedings. Further review of the agreement also revealed it did not address the selection of a neutral venue for arbitration proceedings. The agreement noted Any arbitration conducted pursuant to Article IV (of the admission agreement) shall be conducted at the facility Interview with the Administrator on 04/09/25 at 3:30 P.M. verified the facilities arbitration agreement did not address the selection of a neutral arbitrator or a neutral venue for arbitration proceedings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a follow-up to a pharmacy recommendation for Resident #51 was completed as required. This affected one (Resident #51) of five residents reviewed for unnecessary medications. The facility census was 82. Findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses that included dementia, high cholesterol and insomnia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 was severely cognitively impaired and required extensive assistance of one staff person for completing her activities of daily living. Review of the pharmacy recommendation for Resident #51 dated 02/09/24 revealed the facilities contracted pharmacist recommended to a review of Resident #51's ordered anti-psychotic medication examined for appropriate diagnoses and necessity. Review of the physician's response to the recommendation revealed Resident #51's primary care physician requested a Psychiatric…

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 Based on record review and interview the facility failed to ensure the physician was notified of an elevated lab value for Resident #5. This affected one resident (#5) of three residents reviewed for infections. The facility census was 69. Findings include: Review of the medical record for Resident #5 revealed an admission date of 6/22/2023. Diagnoses included displaced fracture of cervical vertebra, displaced fracture of clavicle, and osteoarthritis. The resident was discharged to the hospital on [DATE]. Review of the Medicare-5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severely impaired cognition. The resident required the extensive assistance of two staff for bed mobility, transfers, walking, dressing, and toilet use. Review of physician orders for August 2023 identified orders for a complete blood count (CBC) and basic metabolic panel (BMP) every Friday starting 07/07/23. A Urinalysis (UA) and Culture and Sensitivity (C&S) were ordered on 08/17/23. Review of lab results from…

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 Based on record review and interview the facility did not ensure Resident #5 was adequately monitored after a change in condition. This affected one resident (#5) of three residents reviewed for change in condition. The facility census was 69. Findings include: Review of the medical record for Resident #5 revealed an admission date of 6/22/2023. Diagnoses included displaced fracture of cervical vertebra, displaced fracture of clavicle, and osteoarthritis. The resident was discharged to the hospital on [DATE]. Review of the Medicare-5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had severely impaired cognition. The resident required the extensive assistance of two staff for bed mobility, transfers, walking, dressing, and toilet use. Review of the Progress Note from 08/18/23 at 9:18 P.M. revealed Resident #5's vital signs were obtained at 8:00 P.M. The resident's blood pressure was 167/59, pulse was 119, respirations 16, temperature was 96.4 degrees Fahrenheit, and the pulse oximeter…

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 Based on interview, record review, and facility procedure review the facility failed to provide copies of the medical record for Resident #222 after request. This affected one resident (Resident #222) of four residents (Resident's #31, #223, #224, and #225) reviewed for the facility honoring the right to have access and/ or purchase copies of medical records upon request. The facility census was 65. Findings include: Review of the closed medical record for Resident #222 revealed an admission date of [DATE]. Resident #222 passed away on [DATE]. Diagnoses included surgical aftercare following surgery on the digestive system, personal history of malignant neoplasm of the liver, severe protein- calorie malnutrition, Alzheimer's disease, and chronic obstructive pulmonary disease. Review of the medical record revealed Resident #222's daughter was her responsible party/ guardian. Review of the letter of guardianship dated [DATE] revealed the court deemed Resident #222 incompetent, and Resident #222's daughter was named…

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 Based on interview, observation, record review, and facility policy review the facility failed to ensure Resident #54's passive range of motion and splint for the right upper extremity was completed per the occupational therapy recommendation. This affected one resident (Resident #54) of one resident reviewed for use of splints. This had the potential to affect five residents (Resident's #1, #10, #18, #53, #54) that had occupational therapy recommendations for splints. The facility census was 65. Findings include: Review of the medical record for Resident #54 revealed an admission date of 01/10/18 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, hypertension, and cognitive communication deficit. Review of the care plan dated 04/27/20 revealed Resident #54 had multiple medical diagnoses including her right side was flaccid and right hemiparesis. Interventions included right hand splint as ordered. There were no interventions regarding passive…

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 and staff interview the facility failed to check all potential new hires against the State Nurse Aide Registry (NAR) to ensure no employee had a finding entered into the NAR concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. This had the potential to affect all 88 residents currently residing in the facility. Findings include: Review of a document titled Phone List by Department, revealed the record reflected 75 State Tested Nurse Aides (STNAs) currently employed at the facility, 32 of which worked on an as needed (PRN) basis. These employees were checked against the State NAR. Review of a document titled New Hires Last 12 Months, dated 08/29/19 revealed the record reflected 14 Licensed Practical Nurses (LPN) #820, #825, #830, #835, #840, #845, #850, #855, #860, #875, #880, #885, #890, and #895. There were four Registered Nurses (RN) #800, #805, #810, and #815. Three housekeeping and laundry staff (Housekeeper) #945, #950, and #955. Seven dietary staff (Dietary) #905, #910, #915, #920, #925, #930, and…

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 observation, record review, and interview, the facility failed to ensure Resident #7 received eating assistance promptly upon the delivery of her food, and had their clothing protector removed when the meal was over. This affected one of four residents reviewed for dignity concerns. The facility census was 88. Findings include: Record review for Resident #7 revealed diagnoses included bipolar disorder, dysphagia, cognitive communication deficit, and dementia. The most recent Minimum Data Set (MDS) assessment revealed the resident was severely cognitively impaired and requiring limited assistance from one staff member when eating. Observation of Resident #7 on 08/26/19 at 12:09 P.M. revealed she was sitting upright in her bed with an uncovered, uneaten lunch tray in front of her. She appeared to be awake, and made no effort to eat the food in front of her. Continuous observation revealed the situation unchanged until 12:27 P.M., when an unidentified State Tested Nurse Aide (STNA) entered the room and began to assist her with eating. A white towel was wrapped around Resident…

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 Based on record review, observation and interview, the facility failed to ensure Resident #41's care plan was revised and updated to meet her individual needs. This affected one (Resident #41) out of 27 residents whose care plans were reviewed. Findings include: Resident #41 was admitted to this facility on 07/24/18. Her admitting diagnoses included vascular dementia, fracture of left femur, dementia, and blindness. Her Minimum Data Set Assessment 3.0 (MDS) dated [DATE] showed this resident had severe cognitive impairment. She needed extensive assistance for bed mobility, toilet use and personal hygiene. For all other activities of daily living she was totally dependant on staff. Her skin assessment from this MDS revealed she was at risk for pressure ulcer development and did at the time of this MDS have skin tears on her legs and arms. This resident resided on the dementia unit and received Hospice services. Review of the resident's plan of care dated 07/25/18 revealed the resident had a potential for actual…

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.