Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% better than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Census: 82
Deficiencies: 3
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication management, arbitration agreements, and nurse aide training at Mount Saint Joseph Rehab Center.
Findings
The facility failed to follow up on a pharmacy recommendation for a psychiatric evaluation for a resident, did not ensure its arbitration agreement included provisions for a neutral arbitrator and venue, and failed to provide required annual in-service training hours for certified nurse aides.
Deficiencies (3)
F 0756: The facility failed to ensure a follow-up psychiatric evaluation was completed as recommended by the pharmacist for Resident #51's antipsychotic medication review.
F 0848: The facility's arbitration agreement did not address the selection of a neutral arbitrator or a neutral venue for arbitration proceedings.
F 0947: The facility failed to ensure certified nurse aides received the required twelve hours of annual in-service training, with one CNA receiving only eight hours in 2024.
Report Facts
Facility census: 82
Hours of continuing education: 8
Number of CNAs reviewed: 3
Number of residents reviewed for unnecessary medications: 5
Residents affected by pharmacy follow-up deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding lack of psychiatric evaluation follow-up for Resident #51 | |
| Administrator | Interviewed regarding arbitration agreement and CNA training deficiencies |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Date: Oct 5, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about the facility's failure to notify a physician of an elevated lab value and inadequate monitoring of Resident #5 after a change in condition.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00146849.
Findings
The facility failed to notify the physician of Resident #5's elevated white blood cell count indicating infection and did not adequately monitor the resident after a change in condition. The resident required extensive assistance and was eventually discharged to the hospital.
Deficiencies (2)
F 0580: The facility failed to ensure the physician was notified of Resident #5's elevated white blood cell count on 08/18/23 indicating infection.
F 0684: The facility did not adequately monitor Resident #5 after a change in condition on 08/18/23 until 08/21/23, despite abnormal vital signs and physician orders.
Report Facts
Facility census: 69
White blood cell count: 34.4
White blood cell count: 11.3
White blood cell count: 11
Vital signs: 167
Vital signs: 59
Vital signs: 119
Vital signs: 16
Vital signs: 96.4
Pulse oximetry: 97
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 10/05/23 verifying lack of documented physician notification and monitoring |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 1
Date: Apr 11, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to timely report an allegation of sexual abuse involving Resident #60.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00141800.
Findings
The facility failed to ensure an allegation of sexual abuse was reported to the state agency as required. The investigation found that Resident #60 initially reported the incident, but staff and administration concluded the resident fabricated the story and did not file a self-reported incident.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities as required by regulation.
Report Facts
Residents affected: 3
Facility census: 64
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Date: Aug 4, 2022
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to provide copies of medical records to Resident #222's legal representative upon request.
Complaint Details
This deficiency substantiates Complaint Number OH00132734 regarding failure to provide medical records to Resident #222's legal representative.
Findings
The facility failed to provide requested medical records to Resident #222's daughter despite multiple requests and emails. Additionally, the facility failed to ensure Resident #54 received appropriate passive range of motion exercises and splint application as recommended by occupational therapy.
Deficiencies (2)
F 0573: The facility failed to provide copies of medical records to Resident #222's legal representative after multiple requests, violating the resident's right to access records.
F 0688: The facility failed to ensure Resident #54 received passive range of motion exercises and splint application per occupational therapy recommendations, affecting the resident's care.
Report Facts
Facility census: 65
Processing fee: 15
Copying fees: 1
Copying fees: 0.5
Copying fees: 0.2
Inspection Report
Annual Inspection
Census: 88
Deficiencies: 6
Date: Aug 29, 2019
Visit Reason
The inspection was conducted as a comprehensive annual survey of Mount Saint Joseph Rehab Center to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including resident dignity during meals, failure to check new hires against the Nurse Aide Registry, inaccurate resident assessments, incomplete care plans, inadequate fall prevention supervision, and failure to report changes in ownership or administrative personnel to the state.
Deficiencies (6)
F 0550: The facility failed to ensure Resident #7 received eating assistance promptly and had their clothing protector removed after the meal.
F 0606: The facility failed to check all potential new hires against the State Nurse Aide Registry to prevent hiring individuals with findings of abuse or neglect.
F 0641: The facility failed to ensure comprehensive assessments were accurate for three residents, omitting mental illness indicators.
F 0657: The facility failed to revise and update Resident #41's care plan to reflect current interventions and needs.
F 0689: The facility failed to prevent a fall with injury when Resident #18 was transported in a wheelchair without footrests, resulting in a head hematoma.
F 0844: The facility failed to inform the Ohio Department of Health about the hiring of a new Director of Nursing.
Report Facts
Facility census: 88
Number of Licensed Practical Nurses hired: 14
Number of Registered Nurses hired: 4
Number of State Tested Nurse Aides employed: 75
Number of State Tested Nurse Aides working PRN: 32
Number of residents reviewed for care plans: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #400 | Licensed Practical Nurse | Confirmed clothing protector was left on Resident #7 after meal |
| LPN #459 | Licensed Practical Nurse | Verified skin tears and bruising on Resident #41 and care plan discrepancies |
| STNA #301 | State Tested Nurse Aide | Involved in Resident #18 fall incident |
| RN #302 | Registered Nurse | Responded to Resident #18 fall and provided assessment |
| MDS Nurse #895 | MDS Nurse | Verified inaccurate comprehensive assessments for Residents #19, #46, and #64 |
| HR #900 | Human Resources | Verified failure to check new hires against Nurse Aide Registry |
| Director of Nursing | Director of Nursing | Verified concerns regarding Resident #7 dignity and Resident #18 fall; hire date not reported to state |
| Administrator | Administrator | Interviewed regarding new hire registry checks and DON reporting |
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