Jamestown Place Health and Rehab

Inspectors wroteBased on medical record reviews, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete Minimum Data Set (MDS) assessments per RAI guidelines. This affected five (#02, #04, #17, #19, and #29) out of sixteen residents reviewed. The facility census was 30. 1)Review of the medical record for Resident #02 revealed an admission date of 11/05/20 with medical diagnoses of end stage renal disease (ESRD), congestive heart failure (CHF), anxiety disorder, hypertension (HTN), and dementia. Review of the medical record for Resident #02 revealed a quarterly MDS assessment, with assessment reference date (ARD) 11/01/25. Review of the MDS assessment revealed the assessment was completed on 11/17/25. 2) Review of the medical record revealed Resident #04 was admitted on [DATE]. [...]

Inspectors wroteBased on medical record review, family interview, and staff interview, the facility failed to ensure care conferences were completed as required. This affected three (#07, #22, and #29) of three residents reviewed for care conferences. The facility also failed to ensure care plans were updated in a timely manner. This affected one (Resident #06) of one resident reviewed for advanced directives. The facility census was 30. 1) Review of the medical record of Resident #07 revealed an admission date of [DATE]. Diagnoses included dementia with agitation, senile degeneration of brain, schizoaffective disorder, bipolar type, chronic obstructive pulmonary disease, repeated falls, depression, gastro-esophageal reflux disease, prostate cancer. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #07 had severely impaired cognition. [...]

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure care-planned fall interventions were in place and failed to implement appropriate fall interventions following an unwitnessed fall. This affected one (Resident #07) of five residents reviewed for falls. The facility also failed to ensure neurological (neuro) checks were completed following unwitnessed falls. This affected five Residents (#06, #07, #19, #25, and #29) of five residents reviewed for falls. The facility census was 30. 1) Review of the medical record of Resident #07 revealed an admission date of 10/09/24. Diagnoses included dementia with agitation, senile degeneration of brain, chronic obstructive pulmonary disease, repeated falls, and prostate cancer. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to implement appropriate infection control practices for residents on transmission-based precautions. This affected four (Residents #06, # 07, #09, and #29) of five residents reviewed for transmission-based precautions (TBP.) The facility also failed to ensure staff performed appropriate hand hygiene after performing catheter care. This affected one (Resident #04) of one resident reviewed for catheter-use. The facility census was 30 residents.

Inspectors wroteBased on record review, observation, family interview, staff interview, and review of facility policies regarding significant changes in resident health status and weight assessment, the facility failed to notify residents' responsible parties of significant changes. This affected two residents (#25 and #07) out of five residents reviewed for notification of changes in status. The facility census was 30.

Inspectors wroteBased on record reviews, staff interviews, and policy reviews, the facility failed to implement the abuse policy upon the discovery of an injury of unknown origin. This affected one (Resident #06) of the one resident reviewed for abuse. The facility census was 30. Review of the medical record for Resident #06 revealed an admission date of 11/09/25. Diagnoses included arthropathy (joint pain), hypertension, chronic kidney disease, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment for Resident #06 dated 01/15/25 revealed a Brief Interview of Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. [...]

Inspectors wroteBased on record reviews, staff interviews, review of Self-Reported Incidents (SRIs), and policy reviews, the facility failed to report an injury of unknown origin to the state agency. This affected one (Resident #06) of the four residents reviewed for falls. The facility census was 30. Review of the medical record for Resident #06 revealed an admission date of 11/09/25. Diagnoses included arthropathy (joint pain), hypertension, chronic kidney disease, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment for Resident #06 dated 01/15/25 revealed a Brief Interview of Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. [...]

Inspectors wroteBased on record reviews, staff interviews, review of Self-Reported Incidents (SRIs) and policy reviews, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (Resident #06) of four residents reviewed for falls. The facility census was 30 Review of the medical record for Resident #06 revealed an admission date of 11/09/25. Diagnoses included arthropathy (joint pain), hypertension, chronic kidney disease, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment for Resident #06 dated 01/15/25 revealed a Brief Interview of Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. [...]

Inspectors wroteBased on staff interviews and record reviews, the facility failed to provide bed hold notices to hospitalized residents. This affected two Residents (#29 and #32) of the four residents reviewed for discharges. The facility also failed to notify the State Ombudsman Agency of a resident's discharge. This affected one (Resident #36) of the four residents reviewed for discharges. The facility total census was 30. 1) Record review for Resident #29 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #29 included diabetes, dysfunction of heart disease, chronic kidney disease, malnutrition, and coronary graft. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed Resident #29 had intact cognition and required set assistance for eating and partial assistance for mobility. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure significant change Minimum Data Set (MDS) assessments were completed in a timely manner. This affected one (Resident #07) of one resident reviewed for hospice services. The facility census was 30. Review of the medical record of Resident #07 revealed an admission date of 10/09/24. Diagnoses included dementia with agitation, senile degeneration of brain, schizoaffective disorder, bipolar type, chronic obstructive pulmonary disease, depression, and prostate cancer. Review of the significant change MDS assessment dated [DATE], revealed Resident #07 had severely impaired cognition. The resident required setup/cleanup assistance with eating, partial/moderate assistance with bed mobility and transfers, substantial/maximal assistance with toileting, and bathing. The assessment was not completed until 11/21/25. [...]

Inspectors wroteBased on review of the medical record, staff interviews, and policy review, the facility failed to ensure a dental care plan was created timely. This affected one (Resident #04) of three residents reviewed for dental services. The facility census was 30. Review of the medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included type II diabetes mellitus (DM II), atrial fibrillation, major depressive disorder, and peripheral vascular disease (PVD). Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #04 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. This resident was assessed to require setup with eating, dependent with toileting and transfers, partial assistance with bathing, and substantial assistance with dressing. [...]

Inspectors wroteBased on review of the medical record, staff interviews, observations, and policy review, the facility failed to ensure dressing changes were changed as ordered. This affected one (Resident #04) of three residents reviewed for skin concerns. The facility census was 30. Review of the medical record revealed Resident #04 was admitted on [DATE]. Diagnoses included type II diabetes mellitus (DM II), atrial fibrillation, major depressive disorder, and peripheral vascular disease (PVD). Review of the physician order dated 11/25/25 revealed Resident #04 was ordered a continuous wound vacuum-assisted closure (Wound Vac) (therapeutic technique using a suction pump, tubing, and a dressing [usually foam] to apply sub-atmospheric pressure to a wound) at 125 millimeters of mercury (mmHg) to be changed every Monday, Wednesday, and Friday every shift. [...]

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly assess a resident's pressure wound upon admission and readmission. This affected one (Resident #32) of one resident reviewed for wound assessment. The facility total census was 30. Record review of Resident #32 revealed the resident was admitted to the facility on [DATE], discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. Diagnoses for Resident #32 included Stage IV pressure ulcer, respiratory failure with atrial fibrillation, hypoxia and hypercapnia, incontinence, and obesity. Review of the census information for Resident #32 revealed the resident was admitted to the facility on [DATE], discharged to the hospital on [DATE] and was readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to implement and execute physician orders to ensure maintenance of acceptable nutrition status parameters. This affected one (Resident #25) out of five residents (#25, #02, #19, #07, and #29) reviewed for weight loss. The facility census was 30. Review of the medical record for Resident #25 revealed the resident was admitted to the facility on [DATE]. Diagnoses included fracture of orbital floor on the right side, fracture of other specified skull and facial bones on the right side, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, generalized anxiety disorder, oropharyngeal dysphagia (difficulty swallowing), muscle weakness, seizures, and underweight status. Review of the weight summary for Resident #25's revealed the resident weighed 164.4 pounds (lbs.) on 07/15/25 (admission). [...]

Inspectors wroteBased on medical record review, staff interview, review of the dialysis contract, and policy review, the facility failed to ensure pre/post dialysis communication forms were completed consistently and thoroughly and failed to ensure pre/post dialysis vital signs and weights were obtained as per physician orders. This affected one (Resident #02) resident who received dialysis. The facility census was 30. Review of the medical record for Resident #02 revealed an admission date of 11/05/2020 with medical diagnoses of end stage renal disease (ESRD) with dependency on dialysis, congestive heart failure (CHF), anxiety disorder, hypertension (HTN), and dementia. [...]

Inspectors wroteBased on medical record review, family interview, and staff interview, the facility failed to ensure care conferences were completed as required. This affected three (#07, #22, and #29) of three residents reviewed for care conferences. The facility also failed to ensure care plans were updated in a timely manner. This affected one (Resident #06) of one resident reviewed for advanced directives. The facility census was 30. 1) Review of the medical record for Resident #04 revealed an admission date of 07/10/25 with medical diagnoses of diabetes mellitus (DM), morbid obesity, hypertension (HTN), chronic kidney disease Stage III, and depression. [...]

Inspectors wroteBased on review of the medical record, observations, staff interviews, and policy review, the facility failed to ensure medication error rate was less than five percent (%) during medication administration pass. This affected two Residents (#31 and #33) of four residents observed for medication administration. The facility census was 30. 1) Review of the medical record for Resident #33 revealed an admission date of 12/09/24. Diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and emphysema. Review of the physician order dated 07/15/25 revealed Keppra 500 milligrams (mg), give one tablet by mouth two times a day for seizures. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of six. [...]

Inspectors wroteBased on staff interviews and record reviews, the facility failed to notify the physician of abnormal laboratory (lab) results/values. This affected one (Resident #29), of one resident reviewed for labs. The total facility census was 30. Record review of Resident #29 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #29 included diabetes, dysfunction of heart disease, chronic kidney disease, malnutrition, and coronary graft. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed Resident #29 had intact cognition and required set-up assistance for eating and partial assistance for mobility. The resident received a carbohydrate controlled and no added salt diet. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure dental services were provided as required. This affected one (Resident #04) of three residents reviewed for dental services. The facility census was 30 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to follow therapeutic diets as ordered by the physician. This affected three (Residents #02, #29 and #32) of three residents reviewed for therapeutic diets. The facility census was 30 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents were provided education on benefits and risks of the Coronavirus (COVID-19) vaccination. This affected two (Residents #02 and #25) of five residents reviewed for vaccinations. The facility census was 30 residents.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain safe clean environment. This had the potential to affect all 30 residents. The facility census was 30. Findings Included: Observation on 10/30/25 at 2:23 P.M. in [NAME] hallway there was staining on the ceiling tile around the water sprinkler which was located close to the nurse's station. Interview on 10/30/25 at 2:23 P.M. with Certified Nurse Assistant (CNA) #135 verified there was staining on the ceiling around the water sprinkler down [NAME] hallway. Observation on 10/30/25 at 2:27 P.M. in Summer hallway the air vents in the ceiling were observed, the second and third air vents from the entrance to the hallway had dust, dirt and debris in them, the sixth air vent was observed with staining on the ceiling around the air vent which had visible dust and debris hanging in the air vent. [...]

Inspectors wroteBased on observation, record review, staff and resident interview, and policy review the facility failed to ensure there was a homelike environment. This affected 11 (# 20, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18) out of 11 reviewed for the environment. The facility census was 34. Findings Included: Observation of Resident #13's room on Winter Hall on 09/15/25 at 8:16 A.M., revealed the bathroom light made a loud screeching noise, the faucet leaked in the sink, and the hot water temperature was 82.7 degrees Fahrenheit. Interview with Resident #13 on 09/15/25 at 8:17 A.M., revealed the light in her bathroom had been screeching for about five or six days, and an aide knew about it, however the resident could not remember her name. [...]

Inspectors wroteBased on medical record review, observation, staff and resident interviews, and policy review the facility failed to ensure residents received two showers a week. This affected five (#25, #29, #20, #8 and #3) of five residents reviewed for bathing. The facility census was 34. Findings Included:1. Medical record review revealed Resident #25 was admitted on [DATE]. Medical diagnoses included encephalopathy and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was severely cognitively impaired. Her functional status was dependent for eating, toileting, bathing and bed mobility. She was non-applicable for transfers. Review of the shower sheets for Resident #25 revealed out of eight shower opportunities the resident received one on 08/21/25 and 09/08/25. The resident had not been out to the hospital. 2. [...]

Inspectors wroteBased on medical record review, staff and resident interview, observation, and policy review the facility failed to ensure fresh water was passed out during the day. This affected four Residents (#26, #19, #24, #29) out of four residents reviewed. The facility identified residents who received nothing by mouth. In addition, the facility failed to ensure a resident with significant weight loss was given his ordered supplement. This affected one resident (#3) of two residents reviewed for weight loss. The facility census was 34. Findings Included:1. Medical record review for Resident #26 revealed an admission date of 05/27/21. Medical diagnoses included quadriplegia, neurogenic bladder, diabetes, and cerebrovascular attack. Review of Resident #26's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure dignity and respect were shown to residents who needed help to eat. This affected three (#25, #26, #7) of three residents reviewed for assistance with eating. The census was 34. Findings Included:1. Medical record review for Resident #25 was admitted on [DATE]. Medical diagnoses included encephalopathy and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was severely cognitively impaired. Her functional status was dependent for eating, toileting, bathing and bed mobility. She was non-applicable for transfers. 2. Medical record review for Resident #26 revealed an admission date of 05/27/21. Medical diagnoses included quadriplegia, neurogenic bladder, diabetes, and cerebrovascular attack. [...]

Inspectors wroteBased on review of the resident council minutes, staff and resident interviews, and policy review the facility failed to ensure resident council concerns had a resolution. This affected two (#13 and #29) of two residents reviewed for resident council. The facility identified not all of the residents were able to attend resident council. The facility census was 34. Findings Included:Review of Resident Council Minutes revealed:On 06/23/25 there was a complaint noted about the facility driveway needed the cracks fixed. On 07/21/25 there was a complaint noted about the facility driveway still needed fixed. On 08/25/25 there was a complaint noted a resident's wheelchair got stuck in a hole out front and the resident could hardly get out of the hole. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review revealed the facility failed to ensure a resident elopement was reported to the state agency. This affected one (#20) of two residents reviewed for elopement. The facility census was 34. Findings Included: Medical record review for Resident #20 revealed an admission date of 10/13/23. Medical diagnoses included non-Alzheimer's dementia, seizure disorder, and schizophrenia. Review of the progress notes dated 05/01/24 revealed Resident #20 had a history of eloping from home. Review of the care plan dated 04/03/25 revealed Resident #20 was identified as an elopement risk and would be wearing a wander guard alarming device. Interventions to prevent elopement included: [...]

Inspectors wroteBased on review of the activity calendar, observation, staff and resident interview, medical record review, and policy review the facility failed to ensure meaningful activities were provided as scheduled. This affected three (#13, #16, #26) of three residents reviewed for activities. This had the potential to affect all of the residents who participated in activities. The facility census was 34. Findings Included:Review of the activity calendar dated 09/01/25 through 09/30/25 revealed on 09/11/25:10:30 A.M. pass mail11:30 A.M. lunch1:30 P.M. bingo 3:30 P.M. manicuresFurther review of the activity calendar for the month of September 2025 revealed every day at 10:30 A.M., was mail and 11:30 A.M., was lunch. Observation on 09/11/25 at 10:30 A.M., revealed no one was passing mail to the residents. At 11:30 A.M., lunch was served to the residents. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the facility investigation statements, staff interview and policy review the facility failed to provide adequate interventions and/or supervision to ensure a resident who was assessed as being at risk for elopement did not elope from the facility. This affected one (#20) of three residents reviewed for elopement. The facility census was 34. Findings Included:Medical record review for Resident #20 revealed an admission date of 10/13/23. Medical diagnoses included non-Alzheimer's dementia, seizure disorder, and schizophrenia. Review of the progress notes dated 05/01/24 revealed Resident #20 has a history of eloping from home. [...]

Inspectors wroteBased on review of the daily staffing, observation and staff interview the facility failed to ensure there was enough staff to assist residents to eat. This affected three (#25, #26, and #7) of three residents reviewed for staffing. The facility census was 34. Findings Included:Review of the daily staffing dated 09/11/25 revealed there were two nurses, and three Certified Nursing Assistants (CNA)'s to take care of 34 residents. There was one CNA who was out of the facility taking a resident to dialysis. The affected three (#25, #26, and #7) of three residents reviewed for assistance with eating.1. Medical record review for Resident #25 was admitted on [DATE]. Medical diagnoses included encephalopathy and non-Alzheimer's dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #25 was severely cognitively impaired. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure the appointed Infection Preventionist had proper infection prevention and control training and certification. This had the potential to affect all the residents in the facility. The facility census was 40.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure advance directives were dated when signed. This affected one (Resident #32) out of four residents reviewed for advance directives. The facility census was 40.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an advanced beneficiary notice of non-coverage was completed. This affected one resident (Resident #36) out of three residents reviewed for beneficiary notice. The facility census was 40.

Inspectors wroteBased on staff interviews and medical record review, the facility failed to complete comprehensive person-centered care plans for two (Resident #14 and Resident #19) out of the four residents sampled. The facility census was 40.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to complete quarterly care conferences for residents and family. This affected one (#39) of two residents reviewed for care plans. The facility census was 40.

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to provide fingernail care to one (Resident #14) out of the four residents sampled. This had the potential to affect all the residents in the facility. The facility census was 40.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to accurately monitor weights per nutritional parameters. This affected three (#8, #20, and #28) out of three residents reviewed for nutrition. The facility census was 40.

Inspectors wroteBased on clinical record review, observation and staff interview, the facility failed to provide to dignity during dining for a resident. This affected one (#11) of 10 residents observed who required assistance/dependence with eating. The facility census was 39.

Inspectors wroteBased on review of the resident fund accounts, staff interview and policy review, the facility failed to provide the resident's funds within 30 days from discharge from the facility. This affected one (Resident #194) of two residents reviewed for a closed fund account. The facility identified eight residents who had a fund accounts with the facility. The facility census was 39.

Inspectors wroteBased on medical record review, staff and family interview and review of the facility policy, the facility failed to ensure a 48-hour baseline care plan was reviewed with the resident and their representative, and a copy of the care plan given to the resident or their representative. This affected one (Resident #15) out of 12 residents reviewed for baseline care plans. The facility census was 39.

Inspectors wroteBased on record review, observations, family and staff interviews and facility procedure review, the facility failed to provide timely and appropriate foot care a resident. This affected one (Resident #22) of one resident reviewed for activities of daily living care. The facility census was 39.

Inspectors wroteBased on observation, medical record review and staff and family interview, the facility failed to ensure Resident #15 received the prescribed amount of enteral nutrition. This affected one (Resident #15) out of one resident reviewed for enteral feeding. The facility identified four residents received tube feedings. The facility census was 39.