James T Champion

In the surveyor’s words

From the most serious findings on record at James T Champion, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF700Apr 24, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to assess the risks associated with the use of bed rails, obtain resident consent, and conduct ongoing evaluations for continued use of bed rails for one (1) of one (1) resident reviewed for bed rail use, Resident #18. This failure had the potential to affect 40 of 63 residents residing in the facility who used side rails. Findings included: A review of the statement provided by the Administrator dated 4/24/25 revealed, There is currently no policy for bed rails . A review of the Siderails and Assist Device Owner's Manual for the bed type used for Resident #18 revealed, . […]

• No harm, potential for more than minimal, patternF909Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure the safe maintenance and monitoring of bed rails in accordance with manufacturer guidelines for one (1) of one (1) resident observed with side rails, Resident #18, which resulted in the lack of required inspections and documentation for side rail safety with the potential to affect 40 of 63 residents who use side rails. Findings include: A record review of the facility's policy statement dated 4/24/25 revealed, There is currently no policy for bed rails. A review of the Siderails and Assist Device Owner's Manual for the bed type used for Resident #18 revealed, .Maintenance/Inspection Information: Visually inspect the assist handle and mounting bracket, and check for loose hardware on a monthly basis . […]

• No harm, potential for more than minimal, isolatedF558Feb 5, 2026

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's call light was maintained within reach as a reasonable accommodation for one (1) of (16) sampled residents. Resident #27.Findings include:A review of the facility's policy, Call Bell/Light, dated July 2024, revealed, .residents will have access to a call bell/light apparatus.3. Procedure A. Nursing Services will ensure that the call bell/light is within easy reach of the resident.A record review of the facility's Professional Development Program Record, dated 1/6/26 and 1/8/26, revealed, .Course Goals & Learning Objectives.Call bell should be within reach at all times.On 2/2/26 at 12:44 PM, during an observation, Resident #27 was observed lying in bed asleep. […]

• No harm, potential for more than minimal, isolatedF605Feb 5, 2026

  Based on interview and record review, the facility failed to ensure as-needed (PRN) orders for psychotropic medications were limited to (14) days unless the medication was re-evaluated and a duration was specified for one (1) of five (5) residents reviewed for unnecessary medications. Resident #13.Findings include:A record review of the Resident Face Sheet revealed the facility admitted Resident #13 on 7/18/25 with diagnoses including Senile Degeneration of Brain and Persistent Mood Disorder.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/26 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident's cognition was severely impaired. […]

• No harm, potential for more than minimal, isolatedF693Feb 5, 2026

  Based on observation, interview, and record review the facility failed to ensure a tube feeding bag was labeled with required information, including the date, time, type of feeding, and initials of the nurse preparing the tube feeding, in accordance with professional standards, for one (1) of two (2) residents reviewed for tube feeding. Resident #11.Findings include:A record review of the Resident Face Sheet revealed the facility admitted Resident #11 on 12/31/25 with diagnoses including Alzheimer's Disease.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/6/26 revealed Resident #11 required a staff assessment for cognitive status and indicated her cognitive skills for daily decision making was severely impaired.A record review of the… […]