St. James Living Center

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the care plan after falls for five residents (Resident #4, #5, #16, #20, and #42) out of 13 sampled residents. The facility census was 43.1. Review of the facility policy titled Care Plan Comprehensive, undated, showed an individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan will be based on a thorough assessment that includes but is not limited to the Minimum Data Set (MDS), a federally mandated assessment tool. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to document the neurological assessments (an assessment completed to determine if the nervous system is impaired) for six residents (#4, #5, #8, #16, #20, and #42) out of 13 sampled residents. Facility staff failed to complete the event documentation for four residents (Resident #4, #8, #20 and #42) out of 13 sampled after falls. The facility census was 43. 1. Review of the facility policy titled Event Investigation, undated, showed the purpose is to investigate the cause of all injuries which have not been witnessed, and to identify any injuries after a resident sustains an event. [...]

Inspectors wroteBased on record review and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for three residents (Resident #7, #16, and #30) out 13 sampled residents. The facility census was 43.1. Review of the facility's policy titled Care Plan, Temporary, undated, showed a temporary care plan will be implemented to meet the new residents' immediate needs. To assure that the residents immediate care needs are met and maintained, a temporary care plan will be implemented for the resident within twenty-four hours of admission. The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed according to the Resident Assessment Instrument (RAI), manual used to complete resident assessments, process. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure safety in the shower room with an unsecured shower drain cover for one resident (Resident #9) out of 13 sampled residents. The facility census was 43. 1. Review of the facility's Preventative Maintenance List, undated, showed it contained a monthly review and checklist of the physical environment for each area of the facility, and did not contain the shower rooms as an area the maintenance staff checked for condition. Review of the policies provided by the facility showed the policies did not contain a policy for reporting maintenance concerns and repairs needed. 2. Review of Resident #9's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Intact cognition; -Used a wheelchair; -Required moderate assist from staff members with bathing; -Had one non-injury fall. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to change one resident's (Resident #9's) of three sampled residents supra-pubic indwelling urinary catheter (flexible tube inserted through the abdomen directly into the bladder to drain urine) per physician's order and failed to provide catheter care. The facility census was 44.1. Review of the facility's policy titled Catheter Care, undated, showed catheter care is to be provided, to prevent infection and reduce irritation. 2. Review of Resident #9's face sheet showed staff documented a diagnosis of Neuromuscular dysfunction of bladder (Nerves that control bladder function are damaged, leading to problems with storing and releasing urine). Review of the resident's care plan, dated 07/03/25, showed staff documented the resident has an indwelling urinary catheter and catheter care should be provided every shift. [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify one resident (Resident #1's) physician, when staff assessed the resident with a significant change in condition and administered Narcan for suspected overdose. The facility census was 45. 1. Review of the facility's Charting and Documentation policy, undated, showed staff are to document any time the physician is called about the resident as well as their response. 2. Review of Resident #1's Baseline care plan, dated 8/4/25, showed staff assessed the resident alert and cognitively intact, experienced seizures. Review showed staff are to monitor medications, provide safe environment, monitor condition and report changes to Director of Nursing (DON) and Physician. Review of the resident's nurse's notes, dated 08/11/2025, showed staff documented the resident was lethargic, with pinpointed pupils, and unresponsive to name. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete an investigation when one resident (Resident #1) overdosed on a Benzodiazepine (a class of central nervous system (CNS) depressants that produce sedation, reduce anxiety, and relax muscles) and administered Narcan (a medication that can rapidly reverse the effects of an opioid overdose. The facility census was 45.1. Review of the facility's Investigation policy, undated, showed facility staff are directed to promptly and thoroughly investigate and try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. When an incident or suspected incident is reported, the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure one resident (Resident #1) remained free from accidents when facility staff failed to remove his/her oxygen and supervise him/her while smoking to ensure his/her safety. On 7/6/25, the resident failed to remove his/her oxygen while smoking in the courtyard and caught fire to his/her nasal cannula which resulted in severe burns to his/her nares and the right side of his/her head. The facility census was 45. The administrator was notified on 7/8/25 of the Past Non-Compliance Immediate Jeopardy (IJ) which occurred on 7/6/25. Upon discovery, the administrator conducted an investigation, notified appropriate parties, and educated Housekeeper A. [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent the misappropriation of medications for two residents (Residents #1 and #2) out of four sampled residents, without the consent of the resident or the resident's representative. The facility census was 50. The administrator was notified on 05/09/25 of past Non-Compliance which occurred on 04/25/25. Staff immediately suspended CMT A, conducted an investigation, and notified the required parties and agencies. The administrator immediately in-serviced staff on the facility's policy regarding counting narcotics and abuse, neglect and misappropriation. Staff terminated CMT A on 04/28/25. The deficiency was corrected on 04/25/25. 1. Review of the facility's Abuse Prohibition Protocol Manual, undated, showed staff are directed as follows: [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when the staff failed to maintain walls, floors, windows, showers and equipment in resident rooms clean and in good repair. Facility staff failed to provide an environment free of pests. The facility census was 48. 1. Review of the facility's policy's showed the facility did not provide a policy for staff to report environmental concerns. 2. Observation on 07/14/24 at 10:00 A.M., showed the water station in front of the nurse's station between the memory care unit and 400 hall contained a dried orange/brown spot on the wall behind and above the trash can. 3. Observation on 07/14/24 at 10:01 A.M., showed the shared bathroom in occupied resident rooms [ROOM NUMBERS] contained yellow stained toilet seat with two cracks in the back side at the hinges. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the comprehensive care plans were updated for oxygen use for two residents (Resident #2, and #41), depression for one resident (Resident #8), behaviors for one resident (Resident #34), wandering for one resident (Resident #36), weight loss for one resident (Resident #41), and for Activities of Daily Living (ADLs) for one resident (Resident #45) out of 23 sampled. The facility census was 48. 1. Review of the facility's policy titled, Care Plan Comprehensive, undated, showed staff were directed as follows: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; [...]

Inspectors wroteBased on observation, record review, and interview, facility staff failed to provide safe hydraulic lift (a mechnical lift used to assist with transferring a resident) transfers for two (Resident #41 and #47) of 23 sampled residents when staff did not ensure the base of the lift was open and stabalized. The facility census was 48. 1. Review of the facility policy titled Hydraulic lift, undated, showed, -The purpose of the policy is to enable one individual to lift and move a resident safely; -The fist step in operating the hydraulic lift is to open lift to the widest point and set the brakes. Review of the facility's hydraulic lift user manual, undated, showed: -When using an adjustable base lift, the legs must be in the maximum opened/ locked position before lifting the patient; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 48. 1. Review of the facility's policies showed the facility did not provide a policy for RN coverage. Review of the Payroll Based Journal (PBJ), a method to collect auditable and verifiable staffing data from nursing facilities, report for Fiscal Year 2024, Quarter 2 (January 1 through March 31) showed triggers for no RN hours for 01/22/24, 02/10/24, 02/11/24, 03/03/24, 03/16/24, 03/17/24, and 03/24/24. 2. Review of the facility's payroll staff hours, dated January 2024, showed the facility did not have an RN in the building for eight consecutive hours on 01/09/24 and 01/14/24. 3. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal care, when staff failed to use Enhanced Barrier Precautions ((EBP), an infection control method that involves wearing gowns and gloves during high-contact resident care activities) for one resident (Resident #19) and perform appropriate hand hygiene, and glove changes during care for two residents (Resident #35 and #47) of 23 sampled residents. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy prior to transfer for four (Residents #2, #8, #19 and #41) of 23 sampled residents. The facility census was 48. 1. Review of the facilities policy titled Discharge/Transfer of Resident, undated, showed: -The purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; -Explain and give copy of bed hold form to the resident and/or representative. 2. Review of Resident #2's medical record showed staff documented the resident had been transferred to the hospital on [DATE] and returned to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, facility staff failed to complete a Significant change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, for three residents (Resident #2, #8 and #41) out of 23 sampled residents. The facility census was 48. 1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/23, shows a significant change is a major decline or improvement in a resident's status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; -Impacts more than one area of the resident's health status; -Requires interdisciplinary review and/or revision of the care plan. 2. Review of Resident #2's SCSA MDS, dated [DATE], showed staff assessed the resident as: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS), a federally mandated assessment tool, when staff did not accurately code weight loss for one resident (Resident #8), restraints for one resident (Resident #34), and anticoagulant and hypnotic medication use for one resident (Resident #16) out of 23 sampled residents. The facility census was 48. 1. Review of the facility's policy titled, MDS and Care Planning Guidelines, dated 10/01/2015, showed it is the policy of the facility to use the most current Centers for Medicare and Medicaid (CMS) MDS Resident Assessment Instrument (RAI) manual, any published interim RAI manual errata documents, and applicable federal guidelines as the authoritative guide for completion of MDS, Care Area Assessments (CAAs), and resident care planning. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility staff also failed to keep the required daily staffing records for eighteen months. The facility census was 48. 1. Review of the facility's policies showed the facility did not have a policy for Daily Nurse staff posting. Review of the facility's records showed the facility did not retain completed nurse staff posting for 4/13/23 through 4/16/23, 6/1/23 through 6/14/23, 6/17/23, 6/18/23, 7/5/23 through 7/16/23. Review showed nurse staff form not available for 4/1/23, 6/12/23, 6/30/23, 11/10/23 through 12/31/23. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure oncoming and off-going staff members verified and reconciled the narcotic count as accurate at each shift change. The facility census was 53. 1. Review of the facility's Narcotic Count Policy, undated, showed staff are directed as follows: -Controlled substances are available only to Licensed Practical Nurses (LPN's), Registered Nurses (RN's), pharmacists, and certified medical technicians (CMT's); -One RN, LPN, CMT going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of narcotics supply for each individual resident at the change of each shift; -After the supply is counted and justified, the nurses/CMT records the date and his/her signature, verifying the count is correct. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent the misappropriation of one resident's (Resident #1's) narcotic medications when Certified Nurse Assistant (CNA) A took the medication without authorization of the residents or the residents' responsible parties. The facility census was 53. 1. Review of the facility's Abuse Prohibition Policy, dated November 2017, showed the policy defined misappropriation of resident's property as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment instrument, dated 9/17/2023, showed staff assessed the resident as follows: -Cognitively Intact; [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide consistent documentation in regard to residents' Life-Sustaining Treatment (designed to improve patient care by creating a medical order form that records residents' treatment wishes so staff know what treatments the resident wants in the event of a medical emergency) for four residents (Resident #7, #204, #206, and #207). The facility census was 55. 1. Review of the facility's Advance Directive policy, undated showed: -Upon admission to the facility, the social service designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advanced directive; [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide a clean, homelike and comfortable environment when staff failed to clean and maintain resident rooms. The facility census was 55. 1. Review of facility's policies showed the facility did not provide an environmental policy. 2. Observation on 5/30/23 at 3:18 P.M., showed the flooring in room [ROOM NUMBER] had debris on the floor. The floor was sticky and had black tape holding the planks of the flooring together with dirt caught in the edges. Observation on 5/30/23 at 2:30 P.M., showed a puddle of urine under the bed on the floor of room [ROOM NUMBER] running from under the bed to the wall of the room. Observation on 5/31/23 at 8:12 A.M., showed Resident #15's room with black strips of tape across several floor tiles with a small corner of one of the tiles raised up. Observation on 6/1/23 at 10:00 A.M. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide residents with a written response to grievances. The facility census was 55. 1. Review of the facility's Resident Grievances policy, undated showed: -A complaint must be in writing and contain the name and address of the person filing it (the grievant); -The complaint shall be investigated by the designee to determine its validity; -The designee shall issue a written decision on the grievance no later than 30 days after filing. Review of the facility's Grievance Protocol policy, undated showed: -The Social Service Director is responsible for the program, although the administrator is ultimately responsible for the proper implementation of the program; -The Social Service Director informs the Administrator of each incident. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or resident's representative of the facility's bed hold policy at the time of transfer to the hospital for five residents (Residents #1, #12, #24, #31 and #48). The facility census was 55. 1. Review of the facility's Bed Hold policy, undated, showed a copy of the policy will be given at the time of transfer to the hospital or leave. Review of the facility's admission Packet showed the facility will notify all residents, and/or their representative of the bed hold policy guidelines. This notification shall be given upon admission to the facility, at the time of transfer to the hospital or leave and at the time of non-covered therapeutic leave. 2. Review of Resident #1's medical record showed the following: -Transferred to the hospital on 5/17/23 and returned on 5/18/23; [...]

Inspectors wroteBased on observation, interview and record review facility staff failed to develop and implement a comprehensive person-centered care plan for four residents (Resident #9, #12, #47, and #204). The facility census was 55. 1. Review of the facility's Care Plan Comprehensive policy, undated showed: -The interdisciplinary team (IDT) with input from the resident, family and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -The IDT is responsible for the periodic review and updating of the care plans when a significant change in the resident's condition occurred, at least quarterly, and when changes occur that impact the resident's care that do not require a significant change. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to follow physician orders when changing one resident's catheter (Resident #7), failed to obtain an order for a catheter for one resident (Resident #1) and staff failed to appropriately sign out administration of Schedule narcotics (drugs based on medical value and potential for abuse as classified by the Drug Enforcement Agency (DEA)) for three residents (Resident #5, #33, and #43). The facility census was 55. 1. Review of the facility's Physician Order policy, undated, showed the content of orders for a catheter should include: -The size and frequency of change; -What the catheter is to be used for. Review of the Catheter Care policy, undated, showed it did not contain direction for catheter orders or following orders. 2. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to assist four out of 14 sampled dependent residents (Resident #12, #27, #28 and #204) with grooming and bathing. The facility census was 55. 1. Review of the facility's Bath (Shower) policy, undated showed it did not contain direction for when to bathe or offer baths, resident preferences, care planning or documentation. Review of the facility's Activities of Daily Living (ADLs) policy, undated showed it did not contain direction for when to bathe or offer baths, resident preferences, care planning or documentation. 2. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/19/23, showed facility staff assessed the resident as: -Cognitively intact; -Had no behaviors and did not reject care; -Required limited assistance of one staff for dressing; [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to ensure hazardous chemicals were stored in a safe manner. The facility census was 55. 1. Review of facility's policies showed the facility did not provide a policy on the storage of hazardous chemicals. Observation on 5/30/23 at 2:19 P.M., showed the 400 hall shower door unlocked with the latch taped open and the chemical Barbazide (a disinfectant for grooming tools) on a counter within the reach of residents. Observation on 5/30/23 at 2:30 P.M., showed the 100 hall shower door unlocked and contained sheet rock screws, a drill with a sheet rock mixing tip, and five gallon buckets with tools within the reach of residents. Observation on 5/31/23 at 10:00 A.M., showed the 100 hall shower door unlocked and contained the sheet rock tools and open boxed of sheet rock screws. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in two of two medication carts sampled. The facility census was 55. 1. Review of the facility's policy on Medications, Storage of, undated, showed staff are directed as follows: -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines; -Drugs must be stored in an orderly manner in cabinets, drawers, or carts. 2. Observation on 6/1/23 at 8:22 A.M., showed the 500 hall medication cart contained: -Three round white tablets loose in the cart; -One large white tablet loose in the cart; -One Blue oval tablet loose in the cart; -One purple oval tablet loose in the cart. 3. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect) in a form and manner accessible to all residents. The facility census was 55. 1. Review of the facility's policies showed the facility did not provided a policy for the required postings. Observations from 5/30/23 at 10:00 A.M. through 6/2/23 at 10:00 A.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse and Neglect Hotline in an accessible location for residents to use if needed. The hotline was posted between the exterior doors at the entranceway with a poster partially covering the number. The secured unit did not have the hotline number posted. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an infection prevention and control program (IPCP) that included an Antibiotic Stewardship Program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 55. 1. Review of the facility's 2022 Facility Assessment showed the facility: -Has an antibiotic stewardship program in place, that has been approved by the governing body to improve antibiotic usage; -Uses infection assessment tools for antibiotic usage; -Has identified the need to check with the pharmacy to see if there are reporting tools to assist the facility in tracking; -Has also identified the need to implement feedback protocols in antibiotic prescribing practices. Review of the facility's Antibiotic Stewardship Program policy, undated, showed: [...]