St. Johns on Fountain Lake

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dishwasher water temperatures in 3 of 3 neighborhood kitchens were monitored to ensure proper sanitization of dishes. In addition, the facility failed to ensure metal pans in the main kitchen were dry before storing. This had the potential to affect all 77 resident who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R19) who was observed to have medications in her room, had been appropriately assessed and deemed safe to self-administer medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure the care plan included management of CPAP (continuous positive airway pressure) for 1 of 3 residents (R24) reviewed for respiratory care. In addition, the facility failed to ensure a care plan was initiated after a trauma assessment identified history of Post Traumatic Stress Disorder for 1 of 1 resident (R27) who was reviewed for mood and behavior.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure individualized activities were provided for 1 of 2 residents (R80) reviewed for activities.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure weekly comprehensive skin assessments (including measurements and characteristics) were completed for 1 of 3 residents (R1) reviewed for pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to assess safe smoking for 1 of 1 resident (R69) reviewed for smoking. In addition, the facility failed to provide a receptable for R69 to safely ash and dispose of cigarettes.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R8) reviewed for hydration and who was dependent upon staff for fluid intake, was offered water/fluids on a consistent basis.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff were following manufacturer's guidelines with continuous positive airway pressure (CPAP) machine with daily maintenance for 1 of 3 resident (R33) reviewed for respiratory care and treatments.

Inspectors wroteBased on observation, interview,, and document review, the facility failed to comprehensively assess and reassess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 resident (R27), reviewed who was evaluated for mood and behavior.

Inspectors wroteBased on interview and document review the facility failed to ensure medications were administered according to physician orders for 1 of 3 residents (R1) reviewed for medication administration. The facility's failures resulted in a significant medication error and an Immediate Jeopardy (IJ) situation for R1 who did not receive an increased dose of Torsemide (treat fluid overload related to heart or kidney disease) ordered by the physician. R1 was admitted to the hospital cardiac intensive care unit (ICU) for worsening congestive heart failure where she remained at the time of the survey. The IJ began on 7/9/25 when staff failed to administer an increased dose of Torsemide as ordered, due to not following the rights of medication administration. This resulted in 11 incorrect doses between 7/9/25 and 7/16/25. [...]

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess and monitor signs/symptoms of fluid overload and failed to implement interventions including notification of changes to the physician for 1 of 3 residents (R3) who had diagnosis of congestive heart failure (CHF) reviewed for change of condition.

Inspectors wroteBased on observation, interview, and document review the facility failed to maintain documentation of actual disposition of medications to include: residents name, medication name, strength, prescription number, quantity, date of disposition, and involved staff and method of destruction for 1 of 5 residents (R1) reviewed for medication disposition.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper infection control practices were followed for 1 of 1 resident (R54) when his urinary drainage bag was observed laying on the floor. Further, loose, and contaminated laundry was observed having been sent down the laundry chute without being secured in a laundry/plastic bag. This had the potential to affect all 68 residents who resided in the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain holding temperatures for hot foods of 135 degrees Fahrenheit or greater. In addition, the facility failed to ensure dietary staff followed appropriate infection control practices during food prep and meal service in the kitchen. This had the potential to affect 22 of 22 residents residing on the unit.

Inspectors wroteBased on interview and document review the facility failed to notify the physician of neck pain following a fall for 1 of 1 resident (R25) reviewed for accidents.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure weekly comprehensive skin assessments with measurements were completed for 1 of 3 residents (R59) reviewed for pressure ulcers.

Inspectors wroteBased on interview and document review the facility failed to act upon the consultant pharmacist's recommendation for 2 of 5 residents (R55, R59) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to utilize enhanced barrier precautions (EBP) for 2 of 5 residents (R1, R2) observed with personal cares.

Inspectors wroteBased on interview and document review the facility failed to safely use a full body mechanical lift per manufacturer's recommendations for 1 of 3 residents (R1) reviewed who used a mechanical lift. This resulted in harm when R1 fell from a full body mechanical lift causing ongoing pain in shoulders and neck region. In addition the facility failed to ensure comprehensive assessments were completed to determine proper sling size for 3 of 3 residents (R1, R2, and R3) who required transfers with a mechanical lift.

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate level care was provided to 1 of 3 residents (R1) reviewed for activities of daily living.

Inspectors wroteBased on interview and document review the facility failed to administer medication per physician order and failed to evaluate and address the medication errors to prevent recurrent medication errors for 1 of 3 residents (R1) reviewed for medication administration.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 2 of 2 resident (R71, R68) who developed pressure ulcers. The facility failure resulted in R71 sustaining harm when the resident developed an unstageable pressure ulcer to left gluteus (butt cheek) along with three additional stage II pressure ulcers on gluteus.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines to prevent the spread of Covid-19, failed to ensure appropriate use of personal protective equipment (PPE) when staff were observed not an wearing N-95 mask in the room of 1 of 1 resident (R20) in transmission based precautions (TBP) for Covid-19; failed to doff (remove) PPE per guidelines when staff were observed removing all PPE after exiting the room of a resident (R20) in TBP for Covid-19 for 1 of 1 resident (R20); failed to ensure precautions posted on resident room doors followed CMS and CDC recommendations for 1 of 1 resident (R20); failed to ensure all staff were fit-tested for use of N-95 masks; this had the potential to affect all 73 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident concerns identified at resident council meetings were addressed and residents notified of a resolution or ongoing measures to ensure compliance. This affected all 11 residents (R10, R11, R13, R15, R16, R32, R43, R45, R46, R50, and R57) who attended resident council.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R19) was notified of lab and x-ray results when requested.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide services to restore, maintain and prevent loss of range of motion (ROM) for 2 of 2 residents (R23 and R40) reviewed for limited ROM.

Inspectors wroteBased on observation, interview and document review, the facility failed to consistently monitor and assess a resident for potential complications related to dialysis treatment and failed to ensure consistent communication with the dialysis facility for 1 of 1 resident (R71) reviewed for dialysis.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the care plan was followed for self-administration of medications for 1 of 1 residents (R3) whose medications were left at R3's bedside.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure hand hygiene was maintained during cares for 1 of 1 resident (R3) observed during personal cares.

Inspectors wroteBased on interview and record review, the facility failed to ensure symptoms of respiratory impairment were assessed and acted upon for 1 of 1 resident (R1) reviewed for change in condition when staff failed update provider with residents change in oxygen saturation.