St James Rehabilitation & Healthcare Center

In the surveyor’s words

From the most serious findings on record at St James Rehabilitation & Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812May 9, 2024

  Based on observation, record review, and interviews during the Recertification survey, initiated on 5/1/2024 and completed on 5/9/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Dining and Kitchen Tasks. Specifically, 1) During the initial tour of the kitchen, opened and undated packages of food were observed in the walk-in freezer and the refrigerator; the walk-in refrigerators and freezer were noted with debris and food spills; and multiple food preparation surfaces in the kitchen were observed with built-up food residue, racks for can storage had a layer of dust; 2) Therapeutic Recreation Aide #1 did not perform hand hygiene after touching the… […]

• No harm, potential for more than minimal, isolatedF656Dec 9, 2025

  Based on observation, record review, and interviews during a recertification survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that a comprehensive person-centered care plan was developed for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for one (1) (Resident #24) of two (2) residents reviewed for Respiratory care. Specifically, Resident #24 has a physician's order for 2 liters of continuous oxygen therapy via nasal cannula. There was no documented evidence that a comprehensive person-centered care plan was developed related to the use of oxygen therapy. […]

• No harm, potential for more than minimal, isolatedF658Dec 9, 2025

  Based on observations, record review and staff interviews during a recertification survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (1) of seven (7) residents reviewed for Pressure Ulcers. Specifically, Certified Nursing Assistant #1, who was not qualified to provide wound care treatment, was observed providing a wound care treatment to Resident #98's stage 3 pressure ulcer during morning care on 12/03/2025. […]

• No harm, potential for more than minimal, isolatedF686Dec 9, 2025

  Based on observation, record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure each resident with pressure ulcers received necessary services consistent with standards of practices to promote healing and prevent infection. This was identified for one (1) (Resident #98) of seven (7) reviewed for pressure ulcers. Specifically, Resident #98 was admitted with a stage two pressure ulcer to right buttocks on 11/26/2025 and there was no documented evidence that wound treatment was ordered and provided to the resident's pressure ulcer until 12/02/2025.The finding is: The Facility Policy for admission assessment dated [DATE] documented to contact the attending physician to communicate and review the findings of… […]

• No harm, potential for more than minimal, isolatedF710Dec 9, 2025

  Based on record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that the medical care of each resident was supervised by a Physician. This was identified for one (1) (Resident #98) of seven (7) residents reviewed for Pressure Ulcers. Specifically, a stage 2 pressure ulcer to Resident #98's right buttocks was identified upon admission on [DATE]. The attending physician did not evaluate the wound and did not ensure that treatment orders were in place until 12/02/2025.The finding is: The facility physician services policy dated 03/06/2025 documented a Physician supervising the medical care of residents includes (but not limited to): prescribing medications and therapy, conducting routine requires visits,… […]