St Joseph Residence

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 4 residents (R) (R57, R18, R40, and R3) of 16 sampled residents.Certified Nursing Assistant in Training (CNAT)-D entered the dining room and placed a ice pack from R57's room on R57's knee. R57 was on enhanced barrier precautions (EBP). Without completing hand hygiene, CNAT-D then passed lunch trays and put clothing protectors on R18, R40, and R57.R18 was on EBP. CNA-E did not don a gown or gloves prior to transferring R18 from recliner to wheelchair.R3 was on EBP. CNA-E emptied R3's catheter bag and removed personal protective equipment (PPE). CNA-E then removed garbage from a can, opened the door, and exited the room without completing hand hygiene. Findings include: The facility's Handwashing - Hand Hygiene policy, dated 5/1/24, indicates: .1. All personnel are trained and regularly in-serviced on 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, staff and resident interview, and record review, the facility did not ensure appropriate respiratory care and services were provided for 2 residents (R) (R18 and R28) of 2 sampled residents. R18 had a continuous positive airway ressure (CPAP) machine. R18 did not have an order to use the CPAP machine or orders to clean the face mask or tubing. R28 used a nebulizer machine. R28's nebulizer tubing was not changed according to the facility's policy. In addition, R28's medical record did not contain orders to change the nebulizer tubing or clean the face mask and other parts of the nebulizer. Findings include: The facility's CPAP/BiPAP (bilevel positive airway pressure) policy, dated 12/1/24, indicates to set the CPAP mode as prescribed, connect supplemental oxygen to the flow rate as prescribed, monitor oxygen saturation of the resident, and clean masks, nasal pillows, and tubing daily. The facility's Administering Medications Through a Small Volume (Handheld) Nebulizer document, dated 1/1/25,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility did not ensure the coordination of Hospice services for 1 resident (R) (R3) of 1 sampled resident.R3 received Hospice services. R3's medical record did not contain a current Hospice care plan and Certified Nursing Assistant (CNA) visit notes were not accessible. In addition, the facility did not coordinate or document bed baths and offer range of motion (ROM) exercises per R3's request.Findings include:The facility's contract with Hospice Company (HC)-J, dated 5/1/21, indicates: Services to be provided by Hospice: .2. Hospice will develop .a plan of care for the management and palliation of the resident's terminal illness .The plan of care will be updated as often as the patient's condition requires, but no less frequently than every 15 days. Part III: Services to be provided by Facility: .2. Facility will provide room and board services to Hospice patients who are residents of the facility, including but not limited to .personal care, and such other…

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 staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 residents (R) (R1 and R2) of 8 sampled residents.On 6/27/25, R1 and R2 were struck by Family Member (FM)-C) in the dining room. FM-C aggressively grabbed at R1, pulled R1 in, and hit R1 in the mid-section with a closed fist. FM-C also slapped R2 on the right hand, grabbed R2's left hand, and pulled R2's wheelchair toward FM-C. The facility did not notify local law enforcement of the abuse.Findings include:The facility's Abuse Prevention and Response policy, revised 1/1/25, indicates: 1. Upon receipt of an allegation or report of an incident, the licensed staff and/or Social Services will .1.3 Contact the police department if there is a suspected crime against a resident. (The facility's policy did not include examples of crimes that should be reported, including but not limited to assault and battery, and did not indicate the facility consulted with local…

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 staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) in a timely manner for 1 resident (R) (R1) of 1 sampled resident. On 10/15/24, R1 reported an allegation of abuse that involved a Certified Nursing Assistant (CNA). The facility did not submit an initial or five-day report to the SA in a timely manner. Findings include: The facility's Abuse Prevention and Response policy, with a review date of 9/23/23, indicates: Any person who becomes aware of alleged abuse, neglect or mistreatment .shall immediately report to the Executive Director .The Executive Director is responsible for receiving allegations of mistreatment, abuse, concerns, and complaints and ensuring the required investigation, reporting and resolution is completed according to State and Federal requirements .External Reporting: .If the suspected allegation does not appear to have caused serious bodily injury to the resident, or there is not a reason to suspect a crime has…

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, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection as observed during the provision of care for 4 Residents (R) (R42, R31, R20, and R34) of 4 sampled residents. Staff did not wear a protective gown during wound care for R42. Staff did not wear the appropriate personal protective equipment (PPE) during an observation of high-contact care for R31 who was on enhanced barrier precautions (EBP). R20 had a history of methicillin-resistant Staphylococcus aureus (MRSA), a chronic wound, and a catheter. The facility did not place R20 on EBP. R34 had chronic bilateral leg wounds that required wound care by the facility. The facility did not place R34 on EBP. Findings include: The facility's Enhanced Barrier Precautions policy, dated 4/26/24, states: Enhanced Barrier Precautions apply to residents utilizing devices or with wounds but are not limited…

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 staff interview and record review, the facility did not notify the State Long Term Care Ombudsman of hospital transfers for 2 Residents (R) (R22 and R43) of 4 residents reviewed for hospitalization. R22 was transferred to the hospital on 5/13/24 and 7/13/24. The State Long Term Care Ombudsman was not provided with written notice of the transfers. R43 was transferred to the hospital on 7/10/24. The State Long Term Care Ombudsman was not provided with written notice of the transfer. Findings include: The facility's Transfer or Discharge Documentation document, revised July 26, 2021, indicates: .4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, the facility will implement the following procedures and document in the medical record: .G. Notify the representative or other family member of the transfer and behold .I. Others will be notified as appropriate or necessary . 1. From 8/5/24 to 8/7/24 Surveyor reviewed R22's medical record which indicated R22 was transferred to the hospital on 5/13/24 and 7/13/24 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.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R20) of 1 sampled resident received the appropriate care and services to prevent urinary tract infections (UTIs). Staff did not ensure R20 received catheter care in a manner that decreased the risk of infection. Findings include: The facility's Catheter Care, Urinary policy, last reviewed 1/1/24, indicates: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .19. Ensure collection bag is kept below the level of the bladder and that bag and tubing is off the floor . From 8/5/24 to 8/7/24, Surveyor reviewed R20's medical record. R20 had diagnoses including intestinal infectious diseases (gastroenteritis and colitis), neuromuscular dysfunction of bladder with indwelling medical device, calculus in bladder, overactive bladder, and paraplegia. R20's Minimum Data Set (MDS) assessment, dated 6/21/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R20 had intact…

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, staff interview, and record review, the facility did not ensure the correct amount of Jevity 1.2 (a nutritional meal supplement) was administered for 1 Resident (R) (R7) of 1 sampled resident. On 8/6/24, Surveyor observed Licensed Practical Nurse (LPN)-D administer one 237 mL (milliliter) container of Jevity 1.2 instead of the 250 mL that was ordered by the physician. Finding include: From 8/5/24 through 8/7/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, adult failure to thrive, dysphagia (difficulty swallowing), and encounter for attention to gastrostomy tube (a medical device used to provide nutrition). R7 had a MIC-KEY tube (an external feeding tube with a button that sits at the level of the skin) through which R7 received nutrition. R7 did not take food or liquid by mouth. R7's medical record contained an order to administer a bolus (single dose given at one time) of 250 mL of Jevity 1.2…

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 staff and resident interview, and record review, the facility did not ensure an individualized comprehensive care plan was developed for 1 Resident (R) (R14) of 19 sampled residents. R14 did not have an individualized care plan that included activities to meet R14's interests and support R14's physical, mental, and psychosocial well-being. Findings include: On 7/10/23 at 11:44 AM, Surveyor interviewed R14 who was upset and stated, I'm bored. I like to go outside. Sometimes I go to activities, but I can't hear, so sometimes I miss out. I live in the apartments over there where my friends are. I want to go home. On 7/10/23, Surveyor reviewed R14's medical record. R14 had diagnoses that included dementia, adult failure to thrive, hearing loss, and generalized weakness with abnormalities of gait and mobility. R14 had an activated Power of Attorney for Health Care (POAHC) who made decisions regarding R14's medical care. R14's MDS assessment, dated 6/19/23, indicated R14's ability to hear was moderate difficulty-speaker has to increase volume and speak distinctly. R14 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, staff interview, and record review, the facility did not ensure 1 Resident (R) (R29) of 2 residents reviewed for pressure injuries received care and treatment to prevent the development of pressure injuries. R29 was at risk for the development of pressure injuries. R29's plan of care contained an intervention for a cushion in R29's recliner. R29 was observed without a cushion in R29's recliner. Findings include: The facility's Prevention of Pressure Injuries policy, last reviewed 1/1/23, contained the following information: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The facility's Support Surface Guidelines policy, last reviewed 1/1/23, contained the following information: Redistribution support surfaces are to promote comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. R29 was admitted to the facility on…

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 staff interview and record review, the facility did not ensure 1 Resident (R) (R17) of 5 sampled residents was monitored for adverse consequences for a high-risk medication. R17 was prescribed furosemide (a diuretic medication). R17's plan of care did not contain monitoring for adverse consequences of furosemide. Findings include: R17 was admitted to the facility on [DATE] and had diagnoses that that included congestive heart failure, dehydration, and hypertension. R17 was prescribed furosemide (used to help treat fluid retention (edema)and swelling caused by congestive heart failure, liver disease, kidney disease, or other medical conditions. Diuretic medications can cause dehydration.) Between 7/10/23 and 7/12/23, Surveyor reviewed R17's medical record and noted R17 was administered furosemide during the following time frames: ~From 3/6/23 through 3/30/23 ~From 5/25/23 through 5/27/23 ~From 6/21/23 through the time of survey. A provider note, 6/2/23, indicated R17 was seen for left leg cellulitis. 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 staff interview and record review, the facility did not ensure 1 Resident (R) (R17) of 5 sampled residents was monitored for adverse consequences of an antipsychotic medication. R17 was prescribed risperidone (an antipsychotic medication) for dementia. R17 did not have a care plan that addressed antipsychotic medication use and contained monitoring interventions for adverse consequences of the medication. Findings include: R17 was admitted to the facility on [DATE] and had diagnoses that included vascular dementia with anxiety and anxiety disorder. R17 was prescribed risperidone which contains a black box warning (the Federal Food and Drug Administration's (FDA's) most stringent warning that alerts the public and health care providers to serious side effects, such as injury or death). Between 7/10/23 and 7/12/23, Surveyor reviewed R17's medical record which indicated R17 was prescribed antipsychotic medication on 2 occasions since admission on [DATE]: ~quetiapine (an antipsychotic medication) 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.