Jamestowne Rehabilitation

In the surveyor’s words

From the most serious findings on record at Jamestowne Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 6, 2026

  Based on record review, observation, staff and resident interview, review of the guidelines from the National Pressure Injury Advisory Panel (NPIAP), and policy review, the facility failed to thoroughly assess a resident's skin and timely identify pressure ulcers (injuries to skin and underlying tissue caused by prolonged pressure, friction, or shear, usually over bony areas like the hips, heels, or tailbone) until they had reached an advanced stage. Actual Harm occurred on 08/03/26 when Resident #40, who was at risk for developing pressure ulcers, developed a facility acquired stage III pressure ulcer (full-thickness skin loss in which adipose [fat] is visible and granulation tissue [new tissue] and epibole [rolled wound edges] are often present. […]

• Actual harm, isolatedF697Nov 4, 2024

  Based on medical record review, observation, resident interview, staff interview, review of the facility policy, and review of online guidance per the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to ensure residents with pain from pressure ulcers were assessed and medicated for pain before, during and after wound care. Actual Harm occurred for Resident #142 when staff failed to assess Resident #142 for pain prior to wound care. Resident #142 reported she was experiencing severe pain prior to wound care and during wound care and the resident moaned and grimaced during the treatment while staff failed to assess for pain and/or offer pain medication or to pause the treatment. This affected one (Resident #142) of three residents reviewed for pain. […]

• Actual harm, isolatedF760Mar 17, 2021

  Based on medical record review, staff and resident representative (RR) interview, review of hospital records, review of a facility investigation report, review of medication error log, review of a vaccination card, review of facility policy and review of an online resource regarding Coronavirus Disease 2019 (COVID-19) vaccine errors, the facility failed to ensure a COVID-19 vaccine was administered to the correct resident resulting in a resident receiving a third dose of the vaccine and a significant medication error. This resulted in actual harm when Resident #29 began having side effects after receiving the third dose of the COVID-19 vaccine and was subsequently admitted to the hospital with an [CONDITION(S)] reaction. This affected one (#29) of three residents sampled. […]

• No harm, potential for more than minimal, widespreadF812Aug 6, 2026

  Based on observation, interviews, and policy review the facility failed to ensure food was prepared, stored, and served in a safe and sanitary manner to prevent the potential of a foodborne illness. This had the potential to affect 25 of 25 residents who eat food prepared in the facility kitchen. The facility identified two (Resident #1 and #61) residents who do not eat food from the facility kitchen. The facility census was 27. Findings Include:Observation of the dish machine temperature log on 08/03/26 at 9:30 A.M. […]

• No harm, potential for more than minimal, widespreadF908Aug 6, 2026

  Based on observation, review of the dish machine temperature log, review of an email correspondence, staff interview, and policy review, the facility failed to ensure the dish machine was maintained in a safe operating condition. This had the potential to affect 25 of 25 residents who received their food from the facility kitchen. The facility identified two (Resident #1 and #61) residents who did not eat from the facility kitchen. The facility census was 27. Findings Include:Observation on 08/03/26 at 9:34 A.M. revealed Senior Director of Culinary (SDC) #382 testing the dish machine. The thermometer was observed broken and a plate thermometer was used to test the temperature inside the dish machine which read 157 degrees Fahrenheit (F).Observation on 8/03/26 at 9:37 A.M. […]