Saint Johns on the Lake

In the surveyor’s words

From the most serious findings on record at Saint Johns on the Lake, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 25, 2022

  Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation), for 1 (R220) of 1 residents reviewed, in accordance with the resident's advance directives. R220 died at the facility on [DATE] without being provided CPR according to physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to ensure that R220 received basic life support, including CPR, in accordance with their advance directives and wishes created a finding of Immediate Jeopardy beginning on [DATE]. NHA-A (Nursing Home Administrator) and DON-B (Director of Nursing)-B were informed of the Immediate Jeopardy finding on [DATE] at 11:10 a.m. The facility removed the immediacy on [DATE] with the implementation of their action plan. […]

• Actual harm, isolatedF686Feb 21, 2023

  Based on observation, interview, and record review, the facility did not ensure 1 (R11) of 2 residents reviewed for pressure injuries had pressure injuries assessed in accordance with current standards of practice to ensure ongoing monitoring to help progress towards improvement. R11 developed a deep tissue injury (DTI) to both heels on 7/26/22. The weekly wound assessment had documentation with no measurements of the wound to show the weekly progression of the pressure injury. On 1/25/23, R11 was assessed by the wound physician to have unstageable pressure injuries. […]

• Actual harm, isolatedF689Jan 25, 2022

  Based on observation, interview, and record review, the Facility did not ensure 1 (R1) of 3 Residents received adequate supervision and assistive devices to prevent accidents. R1 had falls on 7/2/21, 8/3/21, and 10/11/21. On 8/3/21, R1 was reported she slid to the floor from her wheelchair. R1 was noted to have both a ROHO and an Gel cushion in her wheelchair at the time of this incident. There was no documentation in R1's record as to why R1 had both a ROHO and a Gel cushion in her wheelchair at the same time, which is not a standard of practice. On 8/5/21 X-ray's were ordered due to swelling and pain. On 8/6/21, R1 was diagnosed with a right wrist fracture including the distal radius and ulnar bones. […]

• No harm, potential for more than minimal, widespreadF812Jun 3, 2025

  Based on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting all 20 residents that eat food prepared by the facility. *In the facility's main kitchen, observations of partially used and undated food were observed in the walk-in cooler. Open food was observed in the refrigerator in the resident floor main kitchen with no open or use by date. Findings include: The facility policy and procedure titled Food Storage, dated 5/29/2025 documents: Policy, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free of contaminants. […]

• No harm, potential for more than minimal, widespreadF880Jun 3, 2025

  Based on interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 21 residents in the facility. *The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include the infection preventionist as part of the water management plan committee. […]