Saint Albans Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Saint Albans Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 22, 2025

  Based on observation, interview, and record review, the facility failed to assess and identify individual risks and implement measures to provide supervision to prevent accidents resulting in harm to 1 of the 3 sampled residents (Resident #1). Findings include: Per record review, Resident #1 has the following diagnoses: adjustment disorder, borderline personality disorder, anxiety, and major depressive disorder. A review of the initial Minimum Data Set (a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) indicates a BIMS (brief interview for Mental Status) of 15, suggesting that Resident #1 is cognitively intact. […]

• Immediate jeopardy, isolatedF742Jul 22, 2025

  Based on interview and record review, the facility failed to acknowledge and assess the underlying causes of the resident's expression of distress and failed to develop and implement a care plan that addressed this distress, resulting in deterioration of the resident's mental and psychosocial well-being and resulting in the resident harming self for 1 of 3 (Resident #1) of the applicable sample and failed to revise care plans for triggers related to trauma for 9 or 12 residents (Residents #1, #2, #3, #4, #5, #6, #7, and #8). This is a repeat deficiency for this facility, with the violation cited during the previous recertification survey, dated 1/28/25. […]

• No harm, potential for more than minimal, widespreadF584Jan 28, 2025

  Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment regarding resident room maintenance and repair on all resident units. This is a repeat deficiency for this facility, with violations cited during the previous two recertification surveys, dated 10/04/23 and 10/26/22. Findings include: An interview was conducted with the facility's Administrator [ADM] on 1/15/25 at 10:30 AM. The ADM provided a Quality Assurance/Performance Improvement [QAPI] meeting report regarding 'Physical Plant' concerns last dated 1/6/25. Per review of the QAPI report, an audit of the physical plant was assigned and completed by the Administrator, with a notation that all residents have the potential to be affected. […]

• No harm, potential for more than minimal, widespreadF812Jan 28, 2025

  Based on observation, interview, and record review, the facility failed to ensure that freezer food temperatures were maintained at a safe level for 3 of 4 freezers, including the walk-in freezer for the main kitchen that serves food for all residents in the facility. This is a repeat deficiency. Findings include: Per observation on 1/13/25 at 9:54 AM, the walk-in freezer door was unable to shut completely after inspection by the survey team. Review of temperature logs for November and December 2024 reveals that 30 of the 30 days in November the walk-in freezer had recorded temperatures between 5 and 19 degrees Fahrenheit, all days above zero degrees and out of range; and 31 of the 31 days in December the walk-in freezer had recorded temperatures between 3 and 18 degrees Fahrenheit, all… […]

• No harm, potential for more than minimal, widespreadF880Jan 28, 2025

  Based on observation and interview, the facility failed to implement facility-wide systems for the prevention and control of infections and communicable diseases of residents, staff, and visitors. Findings include: 1.) On 1/15/25 at 1:27 PM an inspection of the facility laundry room was conducted. Present for the inspection were the Infection Preventionist [IP] and a Laundry Staff. This surveyor observed three areas in the ceiling where water was dripping from leaking pipes directly into the clean laundry area. When questioned, the facility IP stated that these are drainpipes from the shower room which is located directly above the laundry room. […]