St. Johns Place

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to the Center of Medicaid and Medicare Services (CMS) complete and accurate direct care staffing information for Fiscal Year Quarter Three 2025 (April 1 through June 30) and failed to enter nursing hours in the Payroll Based Journal (PBJ) 9/16/25 through 9/30/25. The census was 56. Review of the facility's Reporting Direct-Care Staffing Information (Payroll-Based Journal policy, dated October 2017, showed:-Policy statement: [...]

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for two of two residents sampled (Residents #49 and #68). The census was 56.1. Review of the facility's admission and Discharge report, dated 12/3/25, showed between 8/1/25 and 12/1/25, there were 11 residents who transferred or discharged from the facility. 2. Review of Resident #49's progress note, dated 11/5/25 at 3:46 P.M., showed the nurse was alerted to the resident's room. Upon assessment, the resident could barely speak. When asked was it hard to breathe, the resident nodded his/her head. Doctor notified of transfer to the hospital. Review of the resident's undated census sheet, located in the electronic medical record, showed the resident discharged to the hospital on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans were updated and accurate to reflect Resident needs. This failure affected three residents (Residents #45, #6 and #44), whose care plans did not accurately address recent falls with interventions and the use of side rails. The sample size was 22. The census was 56. Review of the facility's Care Plan policy, revised December 2016, showed:-A comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident;-The comprehensive, person-centered care plan will: Include measurable and objective time frames; Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure on-going resident centered therapeutic activities were provided to residents on the weekends as an integral part of their psychosocial well-being. In addition, the facility failed to ensure activities were offered to residents who required one on one activities (Residents #2 and #44). This deficient practice had the potential to affect all residents in the facility. The sample size was 22. The census was 56. Review of the facility's Activity Evaluation policy, revised June 2018, showed:-Policy Statement: In order to promote the physical, mental and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could affect his/her participation in planned activities;-Policy Interpretation and Implementation: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Nursing Assistants (NAs) who were employed by the facility were certified within four months of hire, for four out of four sampled NAs. The census was 56. Review of the facility's Nurse Aide Qualifications and Training Requirements policy, dated August 2022, showed:-Policy statement: Nurse aides must undergo a state-approved training program;-Definition: Nurse Aide is any individual providing nursing or nursing-related services to residents in a facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 31 opportunities observed, 8 errors occurred resulting in a 25.80% error rate (Residents #48, #59, #9 and #56). The census was 56. Review of the facility's Adverse Consequences and Medication Errors policy, revised April 2014, showed:-A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional providing services;-Examples of medication errors include: Omission, unauthorized drug, wrong dose, wrong route of administration, wrong dosage form, wrong dug, and wrong time;-Failure to follow manufacturer instructions and/or accepted professional standards. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with acceptable standards of practice. The facility identified one Certified Medication Technician (CMT) cart, one Nurse cart, one treatment cart and one medication room. Two out of the three carts and the medication room were checked for medication storage. Issues were found in the Nurse cart. The census was 56. Review of the facility's Medication Labeling and Storage policy, dated February 2023, showed:-The medication label includes, at a minimum: medication name (generic and/or brand); strength; and resident's name;-For over the counter (OTC) medications in bulk containers (if permitted by state law) the label contains: the medication name; strength; quantity; accessory instructions; lot number; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for two residents (Resident #34 and #8). In addition, the facility failed to ensure staff used good infection control practices for one resident (Resident #19) when staff failed to perform hand hygiene between dirty and clean when personal care was provided and when staff placed the soiled brief and linens directly on the floor. The census was 56. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and respect when a staff member used profanity while speaking on the phone while he/she was in a resident room (Residents #3 and #35) and when staff failed to pull the privacy curtain while providing perineal care (peri-care, cleansing of the genitals and anal area) for one resident (Resident #19). The census was 56. The sample was 22. Review of the facility's Confidentiality of information and personal property policy, revised October 2017, showed:-Policy Statement: The facility will protect and safeguard resident confidentiality and personal privacy;-Policy Interpretation and Implementation:-The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document medications administration on the Medication Administration Record (MAR) for two residents (Residents #48 and #59) and staff failed to document when a resident fell and was sent to the hospital for one resident (Resident#45). The sample was 22. The census was 56. Review of the facility's Physician Services policy, dated April 2013, showed physician orders and progress notes shall be maintained in accordance with current Omnibus Budget Reconciliation Act (OBRA, a federal law impacting Medicaid/SSI eligibility and funding for long-term care) regulations and facility policy. 1. Review of Resident #48's order summary report, showed:-A physician order dated 4/8/25: Dapagliflozin Propanediol (used to treat diabetes) 10 milligrams (mg) by mouth in the morning;-A physician order dated 5/3/25: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their Resident and Family Group Policy and Grievance Policy and Procedure to maintain an effective grievance process for residents in resident council meetings and resolve them in a timely manner. The failure had the potential to affect all residents. The sample size was 4. The census was 54. Review of the facility's Resident and Family Group Policy, undated, showed the following:-Purpose: To ensure residents of facility and their family members or representatives, have the right to organize and participate in resident and family groups. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect two residents from misappropriation of property when former Office Manager (OM) E had one resident write checks made out to OM E to pay for room and board instead of the facility (Resident #1). In addition, OM E mislead a family member make electronic transactions to the employee's personal account to pay for room and board (Resident #11). These monetary transactions were intended as payments for the facility's care and services. The sample was 11. The census was 55. The facility was notified on 7/1/25 of the past non-compliance. The facility terminated OM E. He/She did not return to work following suspension and has had no further engagement with the facility post-investigation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from significant medication errors when the facility failed to administer ordered pain medication for one resident (Resident #5). The sample size was 11. The census was 55. Review of the facility's Medication Orders policy, revised 11/14, showed:-Each resident must be under the care of a licensed physician authorized to practice in this state and must be seen at least every sixty days;-A current list of orders must be maintained in the clinical record of each resident;-When recording orders for medication, specify the type, route, dosage, frequency and strength of the medication ordered. Review of the facility's Controlled Substance Policy, revised 4/19, showed:-Policy Statement: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that nurse aides (NA) completed a nurse aide certification training program within four months of hire for three of 18 NAs, who worked in the facility for more than four months (NA A, NA B, and NA C). The census was 49. Record review of all NA hire dates on 8/27/24, showed: -The facility hired NA A on 4/17/24; -The facility hired NA B on 3/12/24; -The facility hired NA C on 12/28/23; -The three NAs were not certified within the required four-month period. During an interview on 8/27/24 at 11:40 A.M., the Director of Nursing (DON) said she knew all NAs had to be enrolled in a state approved training program which resulted in their certification within four months of hire. The problem the facility was having was getting the NA's to an approved clinical testing location. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to The Center of Medicare and Medicaid services (CMS) complete and accurate direct care staffing information no less frequently than quarterly, for the quarter immediately preceding the annual survey. The census was 45. Review of the facility's Payroll Based Journal (PBJ) staffing Data Report, for fiscal year quarter 1, 2024 ([DATE] through [DATE]), showed the facility triggered for failing to submit data for the quarter. During an interview on [DATE] at 12:24 P.M., the Administrative Assistant and Director of Nursing said PBJ information had not been submitted. The Administrative Assistant said the passwords expired.

Inspectors wroteBased on record review and interview, the facility failed to maintain a surety bond sufficient to ensure the protection of resident funds. The facility census was 45. Review of the facility's Surety Bond Invoice, dated March 19, 2024, showed a bond amount of $100,000.00. Review of the facility's average resident trust fund balance for the previous twelve months, showed: -A monthly average of $73,000.00; -For this amount, the bond amount should have been $109,500.00. During an interview on 3/20/24 at 12:02 P.M., the Facility Accountant said she was unaware of the bond amount and she had been overseeing the accounting over the last six months due to changes in staff. During an interview on 3/20/24 at 12:04 P.M., the Administrative Assistant said he was unaware the bond amount was not sufficient. He would have the bond amount increased immediately.

Inspectors wroteBased on observation and interview, the facility failed to provide to residents a place in the facility where personal phone calls can be conducted in private and without being heard. In addition, the facility failed to ensure residents had access to mail delivered on Saturday. These failures has the potential to affect all residents in the facility. The survey sample was 13. The facility census was 45. 1. Observation on 3/17/24 at 6:40 A.M., showed a small conference room at the beginning of the 100 residents' hall. Signage at the entrance to the conference room read Resident Phone in large green lettering. Observation of the conference room, showed no phone available to residents for private use, but contained multiple office chairs, a table, and a toilet seat cover left on the ground. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a comfortable and homelike environment for residents when staff failed to ensure resident hallways were free from strong odors throughout the survey process. The census was 45. Review of the facility's Departmental (Environmental Services)-Laundry and Linen policy, revised January 2014, showed: -Purpose: The purpose of this procedure is to provide a process for the safe use and aseptic handling, washing and storage of linen; -General Guidelines; -Standard precautions; -Consider all soiled linen to be potentially infectious and handle with standard precautions; -Bagging and Handling Soiled Linen; -All soiled linen must be placed directly into a covered laundry hamper which can contain the moisture. [...]

Inspectors wroteBased on observation and interview, the facility failed to serve food under sanitary conditions when staff failed to store food in a safe and sanitary manner to prevent potential cross-contamination, label and date food items, and failed to ensure pans, bowls and utensils were dry prior to storage. This had the potential to affect all residents who consumed food from the facility kitchen, The facility had a census of 45. Review of the Facility Food Safety High Five Policy, undated, showed; -Do not store raw foods over cooked or ready to eat foods; -Never prepare ready to eat foods on the same surface or with the same utensils used to prepare raw animal proteins; -Properly wash, rinse and sanitize all food contact utensils and equipment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow acceptable standards of practice for infection control for one resident observed during personal care (Resident #30). Staff failed to change their gloves or sanitize their hands after removing a dirty brief and performing perineal care (cleansing of the area including the hips, genitals and anal area), prior to applying a clean brief and touching the resident. In addition, staff failed to apply hand hygiene when handling the residents' meal trays and assisting with meal set-up. Furthermore, facility failed to keep the soiled linens and gowns bagged, tied and off the floor by the residents' rooms. The sample was 13. The census was 45. Review of the facility's Standard Precautions Policy, revised September 2022, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident is treated with dignity and respect when staff stood over residents in the resident use dining room, while assisting the residents with their meals. This affected two out of 13 sampled residents (Residents #11 and #10). The census was 45. Review of the Facility Resident's Rights Policy, revised February 2021, showed: -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -A dignified existence; -To be treated with respect, kindness, and dignity. 1. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/18/24, showed: -Severe cognitive impairment; -Eating: Staff does all of the effort; -Diagnoses included dementia and kidney failure. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate self-determination for residents who were dependent on staff for transfer assistance by failing to ensure residents were out of bed daily, in accordance with resident preferences for two of 13 sampled residents (Residents #30 and #38). The census was 45. Review of the facility's Resident Rights policy, revised February 2021, showed: -Policy Statement: Employees shall treat all residents with kindness, respect and dignity; -Policy Interpretation and Implementation; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: -A dignified existence; -Be treated with respect, kindness and dignity; -Self-determination. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with a mental disorder had a DA-124 Level I screen (Pre-admission Screening and Resident Review (PASARR) used to evaluate for the presence of psychiatric conditions to determine if a PASARR Level II screen is required) as required, for one resident investigated for the PASARR requirement (Residents #6). The census was 45. Review of the facility's admission Policy, revised March 2019, showed: -All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid PASARR process; -The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID or RD; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans to address specific needs of the residents for two of 13 sampled residents (Residents #26 and #6). The census was 45. Review of the Facility Care Plans, Comprehensive Person-Centered Policy, dated March 2022, showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; -The comprehensive, person-centered care plan: -Includes measurable objectives and timeframes; -Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who required assistance with Activities of Daily Living (ADL) care received assistance with meals in accordance with their personal needs for two (Residents #10 and #35) of 13 sampled residents. The census was 45. Review of the Activities of Daily Living (ADL), Supporting Policy, dated March 2018, showed; -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing assistants (NAs) employed by the facility were enrolled in a certification course and that NAs were certified within 4 months of hire. The sample was 9. The census was 41. Review of the facility assessment, reviewed on [DATE], showed: -Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents; -Section 5- Staff Competency Profile Guide: The Centers for Medicare and Medicaid Services pilot for facility needs assessment directs that you look at staff training/education and competencies; -Review of the assessment, showed Section 5 not included in the assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food at time of service was palatable and that hot food was served hot to the residents for one of one meal service observed for food taste and temperature. Residents who reside at the facility reported ongoing concerns with the food being served cold (Resident #2, Resident #4, and Resident #5). The sample was 9. The census was 41. Review of the facility's Preventing Foodborne Illness- Food Handling policy, dated July 2014, showed: -Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized; -Potentially hazardous foods held in the danger zone (41 degrees Fahrenheit (F) to 135 degrees F) for more than 4 hours if being prepared from ingredients at room temperature, or 6 hours if cooled and then cooled will be discarded; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure only residents assessed as safe and appropriate to self-administer medication were allowed to self-administer medications, for one resident observed with medications left at the bedside (Resident #5). The sample was 9. The census was 41. Review of the facility's Self-Administration of Medications policy, dated February 2021, showed: -Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so; -If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for six residents (Resident #6, #7, #10, #26, #39 and #42) out of a sample of 12 and one resident (Resident #35) outside the sample, consistent with the resident rights that included measurable objectives and timeframes that meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The facility census was 41. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, revised December 2016, showed: - The care plan interventions would be derived from a thorough analysis of the information gathered as part of the comprehensive assessment; [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) form when a resident's Medicare covered services had ended for one resident (Resident #27) and to complete and notify in the proper timeframe, at least two calendar days before services were to end, the NOMNC and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for one resident (Resident #22) out of three sampled residents. The facility census was 41. 1. Record review of Resident #22's NOMNC and SNF ABN forms showed: - The resident discharged from skilled Medicare services on 1/19/22, and remained in the facility; - The resident received and signed the forms on 1/22/22; - The facility failed to provide the NOMNC and the SNF ABN forms to the resident at least two calendar days before the skilled Medicare services ended. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS), a federally mandated assessment to be filled out by the facility staff, within 14 days of a resident admitted to hospice. This affected one resident (Resident #26) out of a sample of one resident. The facility census was 41. 1. Record review of Resident #26's medical record showed: - The resident admitted to hospice on 10/28/21. Record review of the resident's MDS's showed: - A significant change MDS, dated [DATE], with no hospice services received; - A quarterly MDS, dated [DATE], with hospice services received; - No significant change MDS, dated within 14 days of the admission to hospice services on 10/28/21; - The facility failed to complete a significant change MDS after the resident admitted to hospice. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for one resident (Resident #9) out of 12 sampled residents and one resident (Resident #35) outside the sample. The facility census was 41. 1. Record review of Resident #9's medical record showed: - Resident did not have an order for an anticoagulant (blood thinner) medication. Record review of the resident's MDS, dated [DATE], showed the resident received an anticoagulant medication in the past seven days. 2. Record review of Resident #35's medical record showed: - The resident did not have an order for an anticoagulant medication. Record review of the resident's MDS, dated [DATE], showed the resident received an anticoagulant medication in the past seven days. [...]

Inspectors wroteBased on interview and record review, the facility failed to prepare a comprehensive discharge summary for one resident (Resident #45) out of one sampled resident. The facility census was 41. 1. Record review of the facility's Discharge Summary and Plan policy, revised December 2016, showed: - When the facility anticipates a resident's discharge to a private residence or another nursing care facility, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment; - The discharge summary will include a recapitulation (summary) of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct procedures were followed when medications were administered through a gastrostomy tube (g-tube) (a tube placed directly into the stomach) which affected one resident (Resident #26) out of two sampled residents. The facility census was 41. Record review of the facility's Administrating Medications through an Enteral Tube policy, revised 11/2018, showed: - Wash hands; - Retrieve medication; - Prepare the medication, check the label and confirm the medication name and dose with the Medication Administration Record; - Prepare the resident; - Check compatibility with feeding tube formula, if feeding would be continuous; - Verify placement of feeding tube; - If improper tube position suspected, do not administer the medication and notify the charge nurse or physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #22) out of one sampled resident. The facility census was 41. Record review of the facility's End-Stage Renal Disease (ESRD), Care of a Resident policy, revised September 2010, showed: - Agreements between the facility and the contracted ESRD facility include all aspects of how the resident's care will be managed including how information will be exchanged between the facilities. 1. Record review of Resident #22's Physician Order Sheet (POS), dated March 2022, showed: - admitted to the facility on [DATE]; - Diagnosis of end stage renal disease (chronic irreversible kidney failure); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure side rails (a structural support attached to the side of the bed to help prevent falls) were used only after other alternatives were attempted, failed to obtain signed informed consent with risks and benefits explained to the resident or representative, and to obtain physician orders for the use of the side rails. This affected four residents (Resident #6, #10, #26 and #39) out of 12 sampled residents and one resident (Resident #4) outside the sample. The facility census was 41. Record review of the facility's Use of Restraints policy, revised April 2017, showed: - Restraints would only be used upon the written order of a physician and after consent obtained from the resident and/or the representative (sponsor); [...]