St. Joseph's Hospital

In the surveyor’s words

From the most serious findings on record at St. Joseph's Hospital, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF605Jul 8, 2026

  Based on record review and staff interview, the facility failed to ensure as needed (PRN) orders for psychotropic medications were limited to 14 days, unless the prescribing practitioner documented a rationale to extend the medication and indicated a duration for the PRN order. This deficient practice had the potential to affect two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident Identifiers: #3 and #13. Facility Census: 15. Findings included: a) Policy and Health System Formulary Review The facility's policy titled, Psychotropic Medications - NCF [Nursing Care Facility], with effective date 04/21/17 and revision date 05/07/21, stated PRN (as needed) psychotropic medications would be ordered for no more than 14 days unless the practitioner felt it… […]

• No harm, potential for more than minimal, patternF759Jul 8, 2026

  Based on observation, record review, and staff interview, the facility failed to ensure observed medication rates were less than five (5) percent. During the medication administration facility task, three (3) errors were observed in 32 medication opportunities to equal an error rate of 9.23 percent. Resident Identifiers: #14 and #15. Facility Census: 15. Findings included: a) Resident #14 On 07/07/26 at 8:12 AM, Licensed Practical Nurse (LPN) #8 was observed administering Resident #14's morning medications. One (1) of the medications administered to Resident 314 was omeprazole (Prilosec). Resident #14's Medication Administration Record (MAR) gave the following administration instructions for Prilosec, Administer capsule with a full glass of water 30 minutes before a meal. […]

• No harm, potential for more than minimal, patternF585Mar 20, 2025

  Based on Resident Council interview, staff interview and policy review, the facility failed to ensure forms were readily available to residents to file grievances. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 15. Findings include: a) Grievance forms During the Resident council meeting on 03/19/25 at 11:00 AM, The Resident Council said that they did not know how to file a grievance and did not know that they could file it anonymously. […]

• No harm, potential for more than minimal, patternF656Mar 20, 2025

  Based on record review and staff interview the facility failed to develop person centered care plans related to activities. This failed practice was found true for (4) four of (5) five residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #9, #5, #8, and #12. Facility census: 15. Findings include: a) Resident #9 A record review on 03/19/25 at 9:00 AM, revealed an activity care plan for Resident #9 that reads as follows: Focus: Resident at risk for isolation due to interest in select activities of her choice and prefers in room activities/socialization. […]

• No harm, potential for more than minimal, patternF679Mar 20, 2025

  Based on Resident Council interview, record review and staff interview the facility failed to provide a program of activities to meet the needs and interests of the residents that included holiday themed and weekend activities. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility census: 15. Findings include: a) The Activity Department During the Resident council meeting on 03/19/25 at 11:00 AM, The resident council said that the weekends are extremely boring. There are activities on the calendar, but no one does them. […]