St. James Rehabilitation & Healthcare Center

Inspectors wroteBased on observation, record review, and interviews during a recertification survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that a comprehensive person-centered care plan was developed for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for one (1) (Resident #24) of two (2) residents reviewed for Respiratory care. Specifically, Resident #24 has a physician's order for 2 liters of continuous oxygen therapy via nasal cannula. There was no documented evidence that a comprehensive person-centered care plan was developed related to the use of oxygen therapy. The finding is:The facility's policy titled Care Plans Comprehensive Person-Centered dated 12/01/2022 documented the comprehensive person-centered care plan includes measurable objectives and time frames. [...]

Inspectors wroteBased on observations, record review and staff interviews during a recertification survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (1) of seven (7) residents reviewed for Pressure Ulcers. Specifically, Certified Nursing Assistant #1, who was not qualified to provide wound care treatment, was observed providing a wound care treatment to Resident #98's stage 3 pressure ulcer during morning care on 12/03/2025. Cross reference F880 Infection Control The finding is: Resident #98 was admitted with diagnoses including non-pressure chronic ulcer of the left calf (back of the lower leg), peripheral vascular disease, and atrial fibrillation. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure each resident with pressure ulcers received necessary services consistent with standards of practices to promote healing and prevent infection. This was identified for one (1) (Resident #98) of seven (7) reviewed for pressure ulcers. Specifically, Resident #98 was admitted with a stage two pressure ulcer to right buttocks on 11/26/2025 and there was no documented evidence that wound treatment was ordered and provided to the resident's pressure ulcer until 12/02/2025. The finding is: [...]

Inspectors wroteBased on record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that the medical care of each resident was supervised by a Physician. This was identified for one (1) (Resident #98) of seven (7) residents reviewed for Pressure Ulcers. Specifically, a stage 2 pressure ulcer to Resident #98's right buttocks was identified upon admission on [DATE]. The attending physician did not evaluate the wound and did not ensure that treatment orders were in place until 12/02/2025. The finding is: The facility physician services policy dated 03/06/2025 documented a Physician supervising the medical care of residents includes (but not limited to): [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that Nurse Aides were able to demonstrate competency in skills and techniques necessary to care for the resident's need. This was identified for one (1) (Resident #1) of one (1) resident reviewed for Accidents. Specifically, Resident #1 reported that they sustained an injury to their left great toe to Certified Nursing Assistant #2 on 12/04/2025; however, there was no documented evidence that Certified Nursing Assistant #2 reported the resident's injury to the nurse. The finding is: The facility policy on Accidents/Incidents last revised 04/2013 documented the facility shall provide a safe and secure environment for staff and residents. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that all medications and biologicals were stored in locked compartments. This was identified for one (1) (Unit 2 North, B medication cart) of four (4) units reviewed during the Medication Storage Task. Specifically, the medication cart for Unit 2 North (B cart) was observed with an unlabeled souffle cup containing one tablet of Januvia 25 milligrams (a medication to lower blood sugar in an adult with type 2 Diabetes Mellitus) in the top drawer. Licensed Practical Nurse #3 confirmed that Resident #49 refused their 06:00 AM Januvia 25 milligrams dose, and instead of discarding the medication, the nurse stored the medication in an unlabeled souffle cup in the medication cart. [...]

Inspectors wroteBased on observations, interviews, and record review during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with their goals and preferences. This was identified for one (1) (Resident #206) of seven (7) residents reviewed for Nutrition. Specifically, Resident #206 had a physician's order for thin liquids and a therapeutic no added salt diet with a mechanically altered chopped texture, related to the diagnosis of heart failure. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. This was identified for two (2) (Resident #09 and Resident #10) of two (2) residents reviewed for Tube Feeding and during the Kitchen task. Specifically, 1) Resident #09 and Resident #10's tube feeding formula and the water bags were unlabeled and did not indicate the resident's name, the date, and the time the tube feeding was initiated. 2) During the tray line service observation on 12/09/2025, the temperature of the prepared cold food items was observed to be above 41 degrees Fahrenheit.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections. This was identified for one (1) (Resident #98) of seven (7) residents reviewed for Pressure Ulcers. Specifically, Resident #98 had Stage 3 pressure ulcers on their bilateral buttocks and sacrum. During morning care on 12/03/2025, Certified Nurse Assistant #1 cleaned the resident's uncovered pressure ulcers with a soiled towel that was used to clean the resident's genital area. The finding is: The Facility Pressure Injury Overview Policy dated 03/06/2025 documented steps of dressing changes including cleaning of the wounds indicating a no touch technique. The policy did not define no touch technique. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification survey, initiated on 5/1/2024 and completed on 5/9/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Dining and Kitchen Tasks. Specifically, 1) During the initial tour of the kitchen, opened and undated packages of food were observed in the walk-in freezer and the refrigerator; the walk-in refrigerators and freezer were noted with debris and food spills; and multiple food preparation surfaces in the kitchen were observed with built-up food residue, racks for can storage had a layer of dust; 2) Therapeutic Recreation Aide #1 did not perform hand hygiene after touching the garbage can and proceeded to open food container on a residents' meal trays.

Inspectors wroteBased on record review, and interviews conducted during the Recertification Survey initiated on 5/1/2024 and completed on 5/09/2024, the facility did not ensure each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. This was identified for one (Resident #82) of one resident reviewed for choices. Specifically, the facility did not allow Resident # 82 to have access to outside food brought in by their family member. The finding is: The facility's Policy and Procedure for Food Brought in by Family last revised in July 2019 documented that if a resident is found eating/being assisted to eat foods/liquids brought from visitors that are not of the proper consistency (per diet order), the resident/visitor will be educated regarding proper food/ drink safety. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey initiated on 5/1/2024 and completed on 5/9/2024, the facility did not ensure that residents were free of any significant medication errors. This was identified for one (Resident #122), of five residents observed during the medication administration task. Specifically, the Physician's order for Resident #122 documented to hold Admelog insulin (a fast-acting insulin that starts to work about 15 minutes after injection, and peaks in about 1 hour) if the resident's blood sugar level was below 300 milligrams per deciliter. Resident #122's blood sugar level was documented as 137 milligrams per deciliter on 5/8/2024 at 6:00 AM. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 5/1/2024 and completed on 5/9/2024 the facility did not provide a sanitary and comfortable environment for residents, staff, and the public. Specifically, four live roaches, one dead roach, and one unidentified crushed insect were observed in the first-floor conference room. Additionally, the kitchen shelf, where the Styrofoam cups were stored, was observed to have a heavy accumulation of dust and debris beneath it. The finding is: The facility policy titled Pest Control dated 10/18/2022 documented the facility has an ongoing pest management program that includes prevention, control of pest activity, and infestation, and ensures that proper handling of all pesticides is in place. [...]

Inspectors wroteBased on observation, record review and staff interviews during the Recertification Survey initiated on 6/15/2022 and completed on 6/27/2022, the facility did not ensure that each resident had a comprehensive person-centered care plan developed and implemented, that included measurable objectives and timeframes to meet the resident's medical and nursing needs. This was identified for one (Resident #33) of one resident reviewed for abuse. Specifically, Resident #33 had a Physician's order for a Peripheral intravenous (PIV) line for Hydration due to an Hypotensive episode and an order for Levaquin (antibiotic) for Pneumonia. There was no documented evidence that a care plan with measurable goals and interventions was developed for the use of the PIV line or antibiotic. The finding is: Resident #33 was admitted with diagnoses that included Hypertension, Pleural Effusion and Pulmonary Edema. [...]

Inspectors wroteBased on observation, record review and interviews and during the Recertification Survey initiated on 6/15/2022 and completed on 6/27/2022, the facility did not ensure that residents who use Psychotropic drugs received Behavioral Interventions in an effort to discontinue these drugs prior to the administration of the as-needed (PRN) Psychotropic medication. This was identified for one (Resident #99) of six residents reviewed for Unnecessary Medications. Specifically, Resident #99 received Alprazolam (Xanax-an antianxiety medication) PRN with no documented evidence that non-pharmacological interventions were attempted prior to the administration of the antianxiety medication. The finding is: [...]