St. Johns Nursing Center

Inspectors wroteBased on observations and interviews, the facility failed to provide food to residents in a safe and sanitary method. This had the potential to affect 154 residents.

Inspectors wroteBased on record review and interview, the facility failed to follow the facility policy of documenting identified changes in the sacral skin condition for 1 of 1 sampled resident reviewed for pressure ulcers, Resident #1.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat residents in a dignified manner for 3 of 3 sampled residents during mealtime observations, Resident #140, Resident #75, and Resident #100; and failed to provide grooming for 1 of 1 sampled resident, Resident #139.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure the residents' call devices were in reach for 3 of 33 sampled residents reviewed for call light accessibility, Residents #85, #153 and #51.

Inspectors wroteBased on interviews and records review, the facility failed to honor 1 of 22 sampled residents, Resident #130's rights for self-determination, as evidenced by the facility's infringement on Resident #130's right to refuse and discontinue nursing home care services.

Inspectors wroteBased on observation, records review, and interview, the facility failed to provide assistance with Activites of Daily Living (ADLs) for 1 of 22 sampled residents, Resident#139, related to removal of facial hair.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow Physician orders for urinary care for 1 of 1 sampled resident, Resident # 152, reviewed for urinary care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to identify weight loss and provide nutritional interventions in a timely manner for 2 of 8 sampled residents reviewed for nutrition, Resident #7, and Resident #140.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow physicians orders for fluid restriction for 1 of 1 sampled resident, Resident #42, reviewed for Dialysis.

Inspectors wroteBased on review of policy and procedure, interview, observation and record review, the facility failed to address social services responsibilities regarding missing personal items and clothing for 1 of 1 sampled resident, Resident #223.

Inspectors wroteBased on observations, interviews and record review, the facility failed to secure dispensed medications which were left unattended on a medication cart, and dispensed medications left at the bedside for a resident during initial observational tour, for 1 of 164 resiudents observed, Resident #374; failed to secure a treatment cart while unattended during wound care observation; and failed to secure an unlocked medication cart review in the facility's third floor wing.

Inspectors wroteBased on review of policy and procedure, observation, interview and record review, the facility failed to ensure it honored the resident's food preferences during a lunch meal for 4 of 33 sampled residents observed, Resident #14, Resident# 151, and Resident #133.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food according to professional standards for food service safety and sanitary conditions and to prevent foodborne illnesses for 2 of 2 observations to the main kitchen.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to disinfect the vital signs machine between residents' usage for Residents #137, Resident #42 and Resident #428; and failed to follow droplet precaution protocol for residents' positive for Coronavirus Disease 2019 (COVID-19), for Resident #375.

Inspectors wrote4. Record review for Resident #137 revealed the resident was admitted to the facility on [DATE] with the following diagnoses that included: Chronic Systolic (Congestive) Heart Failure, Morbid (Severe) Obesity, and Cognitive Communication Deficit. Review of the Minimum Data Set (MDS) for Resident #137 dated 08/11/23 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment; In Section G for bed mobility, the resident had a self-performance of extensive assistance with support of one person assist, for dressing the resident had a self-performance of total dependence with support of two plus persons assist, and for eating the resident had a self-performance of extensive assistance with support of one person assist. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow physicians' orders regarding tube feeding for 1 of 2 sampled residents, Resident #124.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assist with Activities of Daily Living (ADLs) regarding assistance during dining for 1 of 1 sampled resident, Resident #73.

Inspectors wroteBased on observation, interviews, record and policy review, the facility failed to follow physician orders for discontinued medications for 1 of 3 sampled residents reviewed for medication storage on Floor 2 South wing medication cart, Resident #73.

Inspectors wroteBased on observation and interview the facility failed to provide dining in a dignified manner as evidenced by using disposable utensils and serving bowls as observed during lunch meals.

Inspectors wroteBased on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure that it maintained a safe, clean, comfortable, homelike environment for 7 of 7 resident rooms identified during the initial environmental tour (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] for Resident #50 and room [ROOM NUMBER] for Resident #36.)

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop a Baseline Care Plan for fall risk for 1 of 3 residents sampled for accidents (Resident #101).

Inspectors wroteBased on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to provide care and services in accordance with activities of daily living specifically nail grooming for 1 of 2 residents observed for Activities of Daily Living (ADL), Resident #26.

Inspectors wroteBased on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to provide treatment and care for application of a hand splint to address the resident's positioning needs for 3 of 9 residents observed for splints/range of motion (ROM), (Resident #36, Resident #21, and Resident #84).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure indwelling Foley catheter perineal care was conducted in a manner to prevent the potential for infection for 1 of 1 residents observed for Foley catheter perineal care, Resident #75.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status. It failed to provide nutritional interventions in a timely manner to prevent significant weight loss for 3 of 7 sampled residents for nutrition (Resident #101, Resident #73 and Resident #23).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to identify a resident on Dialysis; failed to obtain a physician order for Dialysis; and failed to monitor the Bruit (rumbling sound) and Thrill (rumbling sensation) for 1 of 1 residents reviewed for Dialysis (Resident #590).

Inspectors wroteBased on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to ensure that it secured seven (7) over-the-counter (OTC) medications for 4 of 31 residents observed, Resident #3, Resident #85, Resident #110, and Resident #96. And, failed to assess the residents for Self-Administration of Medications.

Inspectors wroteBased on observation and interview, the facility failed to dispose of the garage and refuse correctly.