Mount Saint Joseph Rehab Center

In the surveyor’s words

From the most serious findings on record at Mount Saint Joseph Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF848Apr 10, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF756Apr 10, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF580Oct 5, 2023

  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 admitted [DATE]. Diagnoses included displaced fracture of cervical vertebra, displaced fracture of clavicle, and osteoarthritis. The resident was discharged to the hospital on 08/27/23. 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. […]

• No harm, potential for more than minimal, isolatedF684Oct 5, 2023

  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 admitted [DATE]. Diagnoses included displaced fracture of cervical vertebra, displaced fracture of clavicle, and osteoarthritis. The resident was discharged to the hospital on 08/27/23. 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. […]

• No harm, potential for more than minimal, isolatedF609Apr 11, 2023

  Based on a record review, staff interview, and facility policy review, the facility failed to ensure an allegation of sexual abuse was reported to the state agency as required. This affected one (#60) of three residents (#5, #6, and #60) reviewed for abuse. The facility census was 64. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE]. Diagnoses included but not limited to viral hepatitis C, seizures, major depressive disorder, personal history of sex reassignment. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/03/23, revealed the resident had severely impaired cognition. The resident required extensive assistance of two staff for bed mobility and transfers. […]