St. James Place Nursing Care Center

Inspectors wroteBased on record reviews and interviews, the facility failed to report an injury of unknown origin to the State Survey Agency immediately, but no later than 24 hours after discovery, for 1 (#32) of 3 residents reviewed for hospitalizations.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident assessments accurately reflected the residents' status. The facility failed to ensure staff accurately coded:The use of restraints and alarms for 1 of 1 (#7) residents reviewed for physical restraints; andThe Functional Limitation in Range of Motion for 1 of 1 (#32) residents reviewed for mobility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure resident weights were accurately documented for 1 of 1 (#1) resident reviewed for weights. Review of the facility's policy Weight Monitoring, with a reviewed date of 10/2025, revealed, in part, the following:Policy Summary and Objective:To establish a standardized process for obtaining, documenting, monitoring, and responding to resident weight changes in accordance with federal regulations, nursing facility requirements, physician orders, and accepted standards of practice. III. Physician-Ordered WeightsAdditional weights shall be obtained as ordered by the physician, nurse practitioner, or physician assistant. Examples include:Daily weights, weekly weights, weights following hospitalization, and weights related to CHF, renal disease, edema, diuretic therapy, nutritional concerns, or other clinical conditions. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain documentation and demonstrate evidence of their ongoing Quality Assurance and Performance Improvement (QAPI) Program. The QAPI committee failed to provide sufficient evidence of documented investigation, data analysis, monitoring, or evaluation of corrective actions put in place after identifying issues with inadequate documentation of resident's weights for 1 (#1) of 1 resident reviewed for weights. This deficient practice had the potential to affect a census of 55 residents.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards for 3 (#1, #2 and #3) of 3 sampled residents reviewed for baths/showers.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to store serving dishes and prepare food under sanitary conditions by failing to ensure ceiling vents in two kitchen locations remained free of thick fluffy gray substance. The deficiency had the potential to affect 58 residents who were served meals from the kitchen.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#32) of 3 (#1, #10, and #32) residents reviewed for Pressure Ulcer/Injury. The facility failed to ensure nursing staff accurately documented Resident #32's weekly body audits.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status for 1 (#41) of 15 sampled residents reviewed for MDS.

Inspectors wroteBased on interviews and record review, the facility failed to meet the following Hospice requirements by failing to maintain a system to ensure a resident's Hospice Binder contained the most recent Hospice Plan of Care for 1(#8) of 2 (#8 and #41) residents reviewed for Hospice care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#254) of 2 (#48 and #254) residents observed with catheters. The facility failed to ensure Resident #254's catheter bag and tubing remained off of the floor.

Inspectors wroteBased on interviews and record review, the facility failed ensure 1 (#11) of 5 (#1, #10, #11, #16, and #254) residents' records reviewed for immunizations had documentation indicating: 1. Resident or resident representative received education regarding the benefits and potential side effects of Pneumococcal and Influenza immunization; and 2. Resident either received, did not receive, or refused the Pneumococcal and Influenza immunization due to medical contraindication.

Inspectors wroteBased on interviews and record review, the facility failed to implement policies and procedures for COVID-19 immunizations for 1 (#11) of 5 (#1, #10, #11, #16 and #254) resident's records reviewed for immunizations. The facility failed to ensure the residents' medical records included documentation that indicated: 1. Residents or resident representatives received education regarding the benefits and potential side effects of COVID-19 immunization; and 2. Residents either received the COVID-19 immunization or did not receive the COVID-19 immunization due to medical contraindication or refusal. The deficient practice had the potential to affect any of the 58 Residents residing in facility who required education and consents for immunizations.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards for 3 of 3 (#1, #2, and #3) sampled residents reviewed for baths.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure nursing staff communicated a significant change in status to the resident's physician or family for 2 (#48, #46) of 4 (#6, #32, #46, and #48) residents reviewed for notification of change. The facility failed to ensure: 1. Nursing staff notified Resident #48's physician after low blood glucose readings were obtained, a change in breath sounds was noted, or a change in level of consciousness occurred; and 2. Nursing staff notified Resident # 46's family after a low blood glucose readings were obtained This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:15 a.m., when S4LPN failed to implement the standing orders for Hypoglycemic Protocol when Resident #48's blood glucose level was 49 mg/dL. S4LPN administered approximately 2 ounces of sugar water via oral swab to the resident. [...]

Inspectors wroteThe facility failed to ensure a resident received treatment and care according to the resident's plan of care and physician's orders in accordance with professional standards of practice by failing to provide needed services. The facility failed to ensure: 1. S4LPN and S5LPN implemented the hypoglycemic protocol for 1 (#48) of 3 (#32, #46, and #48) residents reviewed with Diabetes; and 2. S5LPN assessed an unresponsive resident with gurgled breathing for 1 (#48) of 3 (#32, #46, and #48) residents reviewed with Diabetes. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:15 a.m., when S4LPN failed to implement the standing orders for Hypoglycemic Protocol when Resident #48's blood glucose level was 49 mg/dL. S4LPN administered approximately 2 ounces of sugar water via oral swab to the resident. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure licensed nurses had the necessary competencies and skill sets to care for a resident's needs. The facility failed to ensure: 1. S4LPN and S5LPN implemented the hypoglycemic protocol for 1 (#48) of 3 (#32, #46, and #48) residents reviewed with Diabetes; and 2. S5LPN assessed an unresponsive resident with gurgled breathing for 1 (#48) of 3 (#32, #46, and #48) residents reviewed with Diabetes. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:15 a.m., when S4LPN failed to implement the standing orders for Hypoglycemic Protocol when Resident #48's blood glucose level was 49 mg/dL. S4LPN administered approximately 2 ounces of sugar water via oral swab to the resident. Upon rechecking Resident #48's blood glucose level, the reading was 53 mg/dL. [...]

Inspectors wroteBased on observations and interviews, the facility failed to post the required nurse staffing information on a daily basis for 4 of 4 (Nurse's Station a, b, c, and d) Nurse's Stations reviewed for nurse staffing information.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences by failing to respond to call lights in an appropriate time frame for 2 of 2 (#27 and #33) residents reviewed for call light response.

Inspectors wroteBased on record review and interview, the facility failed to ensure adequate monitoring for side effects with the use of anticoagulant medication was completed for 2 (#32 and #250) of 5 (#11, #32, #36, #47, and #250) residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications by failing to ensure an antipsychotic medication was used only when there was an acceptable diagnosis; and ensure adequate monitoring for effectiveness and side effects of psychotropic medication was completed for 2 (#32 and #250) of 5 (#11, #32, #36, #47, and #250) residents reviewed for unnecessary medications.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect the 49 residents who were served meals from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to a resident or her responsible party for 1 (#6) of 3 (#6, #200 and #201) residents reviewed for Beneficiary Notification. Review of Resident #6's SNF Beneficiary Notification Review Form completed by the facility revealed the following, in part: Medicare Part A Skilled Services episode start date: 02/08/2024 Last covered day of Part A Service: 02/28/2024 How was the Medicare Part A Service Termination/Discharge determined? The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Was a NOMNC, Form CMS-10123 provided to the resident? No An interview was conducted with S2DON on 05/30/2024 at 12:32 p.m. She confirmed a NOMNC was never issued to Resident #6 and/or her responsible party and should have been.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident received adequate supervision and assistance devices to prevent accidents by failing to utilize a Hoyer Lift with the assistance of two staff members for transfers for 1 (#28) of 3 (#28, #33, and #36) residents reviewed with Hoyer Lift transfers.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen tubing and humidifier bottle were properly labeled for 1(#21) of 8 (#5, #18, #21, #30, #41, #46, #250, #251) residents reviewed with oxygen therapy.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) used Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions during a bed bath for 1 (#251) of 6 (#7, #24, #28, #39, #40, and #251) residents reviewed for Enhanced Barrier Precautions.