St. James Wellness Rehab Villas

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was free from a significant medication error. This applies to 1 of 3 residents (R4) reviewed for medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to repair their leaking ice machine in the nourishment room. This applies to 7 of 7 residents (R13, R14, R15, R16, R17, R18, R19) who are ambulatory and with impaired cognition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely incontinence care for residents who require assistance with toileting and hygiene. This applies to 3 of 4 residents (R1, R2, R3) reviewed for activities of daily living (ADL) care in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for wound treatment and wound dressing changes as needed. This applies to 1 of 3 resident reviewed for wounds in the sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that there is a physician order for self-administration of an inhaler medication, and failed to ensure that medication was administered to residents accurately as prescribed by physician. This applies to 2 of 7 residents (R1 and R5) reviewed for medication administration in the sample of 19.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement physician's orders. This applies to 4 of 4 residents (R1-R4) reviewed for history of UTIs (urinary tract infections).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide proper catheter care for 4 of 4 residents (R1-R4) that were reviewed for catheter care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enough clean linens, blankets, towels, and wash cloths were available for the residents. This applies to all the 69 residents in the building reviewed for a homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to notify the POA (Power of Attorney) and physician of changes in condition. This applies to 1 of 1 resident (R1) reviewed for notification of changes.

Inspectors wroteBased on interview and record review, the facility failed to provide needed wound care treatment services and manage abnormal vital signs for a resident with Covid. This applies to 1 of 1 resident (R1) reviewed for improper nursing care.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 80 residents in the facility receiving dietary services.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the kitchen dishwasher and sink in good repair. This applies to 80 residents in the facility receiving dietary services.

Inspectors wroteBased on interview and record review, the facility failed to provide a resident and/or their family/POA (POA/Power of Attorney) in writing of the reason for transfer to the hospital. The facility also failed to notify the ombudsman of the transfer. This applies to 6 of 6 residents (R26, R35, R50, R68, R72, and R73) reviewed for discharge in a sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide in writing to the residents and/or their POA (POA/Power of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 6 of 6 residents (R26, R35, R50, R68, R72, and R73) reviewed for discharge in a sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL care (Activities of Daily Living) for 5 residents (R20, R69, R10, R62, & R5) who are dependent on care for daily living in a sample of 30.

Inspectors wroteBased on observation, interview and record review, the facility failed to have fall interventions in place for 4 residents (R20, R51, R71, & R83) who are at risk for falls in a sample of 30.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain physician orders for over-the-counter medications and to have medications stored in resident rooms. This applies to 6 of 6 residents (R13, R58, R66, R67, R72 and R73) reviewed for medications in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices with regards to hand hygiene during provisions of bowel/bladder care and wound care, no signage for residents in EBP (Enhanced Barrier Precautions), improper disposal of PPE (Personal Protective Equipment), and improper practices for residents on transmission base precautions. This applies to 8 residents (R83, R54, R59, R62, R88, R13, R39, R73) reviewed for infection control in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly position resident's indwelling catheter bag/drainage bag during wound care dressing change. The facility failed to provide incontinent care to residents in a timely manner. This applies of 6 of 6 residents (R14, R24, R29, R71, R73 and R83) reviewed for indwelling catheters and incontinent care in a sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 2 residents (R5 & R10) received oxygen as their physician ordered in a sample of 30.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' call light system was functioning properly. This applies to 2 of 2 residents (R39 and R42) reviewed for functioning call lights in a sample of 30.

Inspectors wroteBased on interview and record review the facility failed to notify a Physician for a resident change in condition. This applies to 1 of 3 residents (R1) reviewed for change in condition in a sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Covid-19 infection control policy and The State Agency guidelines on COVID-19 by having COVID-positive residents and asymptomatic/COVID-negative residents in the same room to prevent a potential outbreak. This applies to 4 of 8 residents (R1, R3, R5, and R7) reviewed in a sample of 9.

Inspectors wroteBased on observations, interviews, and record review. The facility failed to conduct water testing and monitoring to prevent waterborne pathogens, this applies to 71 of 71 residents that reside in the facility. The facility also failed to identify and properly store resident personal care items and perform hand hygiene during incontinence care. This applies to 7 of 7 residents (R1, R30, R40, R44, R52, R53, R169) reviewed for infection control in a sample size of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal hygiene assistance to meet the needs of residents. This applies to 8 residents (R49, R65, R19, R26, R46, R7, R51, and R20) reviewed for ADL's (Activities of Daily Living) in a sample of 24 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to place a bed in a safe position. This applies to 1 of 1 resident (R170) reviewed for falls in a sample of 24.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide proper incontinence care for 2 of 2 residents (R30 and R52) observed for incontinence care in a sample of 24.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to contain reusable nebulizer treatment masks, and BIPAP masks (bilevel positive airway pressure). This applies to 3 residents (R3, R20, & R45) reviewed for respiratory care in a sample of 24.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to appropriately store medications and biologicals safely for 2 residents (R34, R173) in a sample of 24.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe environment for 1 of 1 resident (R20) in a sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard nursing practices with regards to hand hygiene and glove changing during provisions of incontinence care. This applies to 4 of 4 residents (R14, R15, R61 and R22) reviewed for improper nursing in a sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nutrition supplements and fluid restriction as ordered by the Physician. This applies to 4 of 4 residents (R3, R8, R36, R41) observed for dining in the sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to ensure that consents containing risk information for the use of psychotropic medications were obtained prior to administration. This applies to 1 of 3 residents (R35) reviewed for psychotropic medications in the sample of 20 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene. This applies to 3 of 3 residents (R36, R61, R129) reviewed for activities of daily living in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and provide adaptive equipment to a resident, to prevent further reduction in mobility and ROM (Range of Motion). This applies to 1 of 2 residents (R65) reviewed for limited range of motion in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed provide incontinence care in a manner that would prevent potential urinary tract infection (UTI). This applies to 3 of 4 residents (R14, R15, R61) reviewed for incontinence care in the sample of 20.