Saint Johns on the Lake

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R1) of 1 allegations of abuse or neglect reviewed.*The care plan was delayed in being updated and a key intervention was not added after the investigation was completed. The investigation was not thorough, no like-resident interviews were conducted and the five days of wellness checks facility proposed to monitor R1 after the incident were not completed.

Inspectors wroteBased on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting all 20 residents that eat food prepared by the facility. *In the facility's main kitchen, observations of partially used and undated food were observed in the walk-in cooler. Open food was observed in the refrigerator in the resident floor main kitchen with no open or use by date.

Inspectors wroteBased on interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 21 residents in the facility. *The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include the infection preventionist as part of the water management plan committee. - Identify corrective actions when control limits do not meet acceptable ranges of control limits (temperature ranges). *The facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris.

Inspectors wroteBased upon observation, interview and record review the facility did not ensure they had a system in place to ensure monitoring of and maintaining of laundry vents that extended up from the laundry room to the outside. This has the potential to effect all 21 Residents residing in the facility. *The facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris.

Inspectors wroteBased on interview and record review, the facility did not ensure a resident who uses a psychotropic PRN (as needed) drug had an order limited to 14 days for 1 (R6) of 5 residents reviewed for unnecessary medications. R6 had an order for PRN Ativan with a start date of 5/17/2025 and no end date.

Inspectors wroteBased on interview and record review, the facility did not ensure for 1 (R16) of 1 residents reviewed for a level 1 and level 2 PASARR (Preadmission Screening and Resident Review) had the screenings completed as required. *R16 did not have a PASARR level 1 screen completed prior to admission to the facility. A level 1 screen was completed on the day of admission. Additionally, the facility did not ensure a level 2 screen was completed based upon the results of the level 1 screen.

Inspectors wroteBased on interview, and record review the facility did not include 1 (R15) of 2 residents reviewed for antibiotic stewardship on the facility line listing to ensure antibiotic use was monitored per facility protocols and ensure the antibiotic administration was included as part of the overall facility infection prevention and control program. *R15 was receiving an intravenous (IV) Antibiotic (ABT) and was not added to the antibiotic/infection control line list. The line list is part of the antibiotic stewardship program which allows the facility to monitor and track antibiotic use and infections.

Inspectors wroteBased on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to effect all 21 residents in the facility. *The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1 (R11) of 2 residents reviewed for pressure injuries had pressure injuries assessed in accordance with current standards of practice to ensure ongoing monitoring to help progress towards improvement. R11 developed a deep tissue injury (DTI) to both heels on 7/26/22. The weekly wound assessment had documentation with no measurements of the wound to show the weekly progression of the pressure injury. On 1/25/23, R11 was assessed by the wound physician to have unstageable pressure injuries.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure staff working in the kitchen followed standards of practice for proper handling of food while maintaining hand hygiene. This had the potential to effect 8 out of 23 residents who eat food prepared in the main kitchen. Cook-F was observed donning gloves after washing her hands, Cook-F then proceeded to touch menus, contaminating her hands. Cook-F did not change gloves or rewash her hands before proceeding to prepare sandwiches for residents.

Inspectors wroteBased on interview and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 2 (R6 and R10) residents reviewed for weights. R6 did not have monthly weights done as ordered. R10 did not have weekly weights done as ordered.

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R6 and R10) of 12 residents had physician orders transcribed correctly. R6 was admitted to the facility on [DATE] and had an order for Tobramycin that was not transcribed correctly and then was not administered as ordered. R10 had an order for an antibiotic that was not transcribed correctly and was given the medication past the prescribed stop date.

Inspectors wroteBased on interview and record review the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 (R10) residents reviewed. R10 received Levofloxacin (antibiotic) for an excessive duration and without adequate indications for its use.

Inspectors wroteBased on observation, interview and record review the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 3 of 3 residents (R4, R11 and R124) residing on the unit. The glucometer, which is shared between residents, was not cleaned according to the label instructions.