St Joseph Villa

Based on interview, the facility did to employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 7/8/24 at 8:48 AM, an interview was conducted with the DM. The DM stated she had not completed the required certification to work as the dietary manager. The DM stated the facility had a contracted RD that was at the facility on Mondays, Tuesdays, and Thursdays, and that she was always available by phone. On 7/16/24 at 4:02 PM, a second interview was conducted with the DM. The DM stated she had not completed a course in food service safety and management, a Certified Dietary Manager course, a certified food service manager course, or a nationally recognized certification or associates degree or higher in food service and safety.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 52 of 89 sampled residents, that the facility did not keep confidential all information contained in the resident's records, regardless of the form or storage method of the records. Additionally, the facility did not maintain the medical records on each resident that were complete, accurately documented, and readily accessible. Specifically, residents' names were included in a different residents medical records, and a resident's medical records from the hospital were not included in the residents electronic medical records at the facility. Resident identifiers: 2, 3, 4, 6, 8, 13, 16, 22, 23, 25, 26, 28, 29, 36, 45, 55, 63, 66, 68, 69, 70, 71, 81, 85, 88, 89, 91, 93, 100, 103, 105, 109, 111, 112, 113, 117, 119, 137, 138, 139, 141, 145, 217, 218, 219, 220, 221, 222, 223, 224, 225 and 363. Findings Included: 1. The following form entitled Orders dated 1/15/24 was located in resident 4, 221, 145, 91, 6, 3, 88, 8, 222, 109, 22, 66 and 103's electronic…

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 and record review, it was found that the facility failed to ensure that a resident received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 89 sampled residents. Specifically, a resident with a pressure injury was not provided dressing changes for 12 days. Resident identifier: 129. Findings include: Resident 129 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included encephalopathy, bacteremia, fistula of intestine, colostomy, severe protein-calorie malnutrition, hypomagnesemia, hypocalcemia, vitamin D deficiency, anemia, chronic kidney disease stage 3, pressure ulcer of sacral region, depression, and adult failure to thrive. Resident 129's medical record was reviewed from 7/8/24 through 7/16/24. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 129 had a Brief Interview for Mental Status (BIMS) score of 14,…

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 observation, interview and record review it was determined, for 1 of 89 sampled residents, that the facility did not provide or obtain outside resources for routine and emergency dental services to meet the needs of the residents. Specifically, a resident was not provided dental services after requesting to see one. Resident identifier: 38. Findings include: Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fibromyalgia, systemic lupus erythematosus, chronic pain syndrome, depression, generalized anxiety, and cognitive communication deficit. On 7/10/24 at 1:32 PM, an interview was conducted with resident 38. Resident 38 stated that she has not seen a dentist and would like to see one. Resident 38 stated that she has several missing teeth, and it is hard for her to chew. Resident 38's medical record was reviewed 7/8/23 through 7/16/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 38 had a broken or loosely…

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 and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Specifically, a resident was noted to have bruising on his shoulder, but this was not reported as possible neglect or abuse for approximately 2 days. Resident identifier: 217. Findings include: Resident 217 was admitted to 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 Based on observation, record review, and interview it was determined, for 1 of 42 sampled residents, that the facility did not ensure that the resident's right to self-administer medications was evaluated by the interdisciplinary team and was determined to be clinically appropriate. Specifically, a resident self administered their medications without an evaluation to determine if it was safe for the resident to exercise that right. Resident identifier: 77. Findings included: Resident 77 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, morbid obesity, chronic pain, heart failure, hypertension, major depressive disorder, osteoarthritis, cognitive communication deficit, peripheral vascular disease, tremor, and gastro-esophageal reflux disease. On 8/30/22 at 8:24 AM, an interview was conducted with resident 77. Resident 77 stated that she had constant abdominal pain due to kidney stones. Resident 77 stated that she received medication for the pain and then…

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 observation, interview, and record review, it was determined, the facility did not ensure that when the use of restraints was indicated, the facility used the least restrictive alternative for the least amount of time. Specifically, for 1 out of 42 sampled residents, a resident with a seatbelt was unable to release it. Staff were not observed to release the restraint and reposition the resident for over 3 hours. Resident identifier: 12. Findings included: Resident 12 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cerebral palsy, type 2 diabetes mellitus, neuromuscular dysfunction of bladder, dysphagia, need for assistance with personal care, contracture left hip, limitation of activities due to disability, contracture of muscle right forearm, contracture right knee, contracture left knee, major depressive disorder, contracture unspecified joint, contracture of muscle right hand, muscle weakness, and retention of urine. On 8/29/22 at 2:24 PM,…

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 and interview it was determined that the facility did not ensure that the resident's medical records were secured and confidential. Specifically, observations were made of computer screens left unattended and displaying resident personal information. In addition, residents were observed in the area with the unattended computer screens. Findings include: On 3/3/20 at 8:03 AM, Registered Nurse (RN) 2 was observed to walk away from a computer that was on the medication cart located in the hallway on the northeast side of the 3rd floor. The computer screen was observed to have resident information open and visible. There were five residents observed sitting around the area of the unattended open computer screen. On 3/4/20 at 7:08 AM, RN 1 was observed to walked away from a computer on a medication cart with a residents medical record open and visible. The computer was by the North [NAME] nurses' station on the 2nd floor. The open computer screen was observed to be unattended for 3 minutes. On 3/4/20 at 7:35 AM, RN 3 was observed to leave person identifying…

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 observation, interview, and record review it was determined that the facility did not ensure that the drugs were label according to accepted professional principles and stored in a locked compartment. Specifically, medications were found in resident's rooms, and medication carts were not kept secured. Findings include: 1. On 3/2/20 at 7:30 AM, an observation was made of room [ROOM NUMBER] with a bottle of Advil and fluticasone nasal spray on the resident's bedside table. 2. On 3/2/20 at 7:34 AM, an observation was made of room [ROOM NUMBER] with an unlabeled medication cup on the resident's shelf; the cup contained a white powder. 3. On 3/4/20 at 7:32 AM, an observation was made of Registered Nurse (RN) 1. RN 1 left the medication cart unlocked and unattended while administering medications to a resident. RN 1 stated he was going to wash his hands. RN 1 was observed to go into the bathroom. RN 1 returned to the cart at 7:34 AM. 4. On 3/4/20 at 8:03 AM, an observation was made of the third East…

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, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were cracked tiles in the dishmachine area that had pooling water, there was pealing paint above the food preparation area, and there were soiled areas behind the equipment. Findings include: 1. On 3/2/20 at 7:40 AM, an initial tour of the kitchen was conducted. The following was observed: a. There were 2 spots of pealing paint on the ceiling in the kitchen. Food was observed to be transported under the pealing paint. b. There was dust and debris behind the ovens, stove, steamer and griddle. c. There were 4 broken tiles in the dishmachine area. There was water pooling in the area that pieces of tiles were missing. 2. On 3/4/20 at approximately 12:30 PM, a follow up kitchen tour was conducted. The following was observed: a. There were 2 spots of pealing pain on the ceiling in the kitchen. Food was observed to be transported under the pealing paint. b. There was…

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 observation and interview the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed to cross contamination while serving residents in the dining room. In addition, hygiene products in shared bathrooms were not labeled. Resident identifiers: 46, 48 Findings include: 1. On 3/2/20 at 8:00 AM, Certified Nursing Assistant (CNA) 2 was observed in the 3rd floor dining room assisting two residents with eating. CNA 2 was observed to finger sweep of resident 48's mouth with her index finger to remove a large amount of chewed but unswallowed food. CNA 2 was not observed to use a glove, CNA 2 was observed to wrap a cloth napkin around her index finger prior to placing her finger in resident 48's mouth. After removing the unswallowed food CNA 2 placed the napkin on the table and began feeding…

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.