St James Wellness Rehab Villas

In the surveyor’s words

From the most serious findings on record at St James Wellness Rehab Villas, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure that a resident with a dementia diagnosis and a wander monitoring device was prevented from eloping from the facility in the night. This failure resulted in R1 exiting the facility unnoticed and unsupervised and walking across an intersection to a gas station until a person from the community notified the police. This failure resulted in Immediate Jeopardy (IJ). The Immediate Jeopardy was noted to begin on February 9th, 2023, when R1 eloped from the facility unwitnessed by staff. […]

• No harm, potential for more than minimal, widespreadF584Jan 7, 2025

  Based on observation, interview, and record review the facility failed to ensure enough clean linens, blankets, towels, and wash cloths were available for the residents. This applies to all the 69 residents in the building reviewed for a homelike environment. Findings include: On 01/02/25 at 9:24 AM, V2 DON (Director of Nursing) stated the facility census is 69. Facility's Data Sheet dated 12/31/24 also indicated their total census is 69. On 12/31/24 at 10:56 AM, R1 stated that she has made a list of items that the facility doesn't have. R1 stated that there were no bed pads the previous night and facility staff had given her their last sheet. R1 stated there were no wash rags available and no Kleenex. […]

• No harm, potential for more than minimal, widespreadF812Dec 6, 2024

  Based on observation, interview, and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 80 residents in the facility receiving dietary services. Findings include: On [DATE] 10:55 AM, V26 (Dietary Manager) stated 80 residents were served from dietary services on [DATE]. On [DATE] at 10:01 AM, the kitchen tour was conducted with V26. The dry storage contained a facility contained labeled [NAME] powder was dated [DATE]. On [DATE] at 10:08 AM, the walk-in cooler contained a shelf labeled employee items included two personal lunch bags with food items, an 18 oz bottle of barbeque sauce, three unlabeled cups take sauce cups two with red sauce one with green sauce. Sliced Jalapenos 64 ounces dated [DATE]. […]

• No harm, potential for more than minimal, widespreadF908Dec 6, 2024

  Based on observation, interview, and record review the facility failed to maintain the kitchen dishwasher and sink in good repair. This applies to 80 residents in the facility receiving dietary services. Findings include: On 12/05/24 10:55 AM, V26 (Dietary Manager) stated 80 residents were served from dietary services on 12/3/24. On 12/03/24 at 10:33 AM, V26 was unable to run the dishwasher stating it is currently not working. The trough like sink near the dishwasher was filled with dirty water. Covered shelves containing neatly stacked dishware declared clean by V26 Dietary Manager and V27 Assistant Dietary Manager were caked with yellow crusts, dried food, and small dead black bugs. […]

• No harm, potential for more than minimal, widespreadF880Nov 17, 2023

  Based on observations, interviews, and record review. The facility failed to conduct water testing and monitoring to prevent waterborne pathogens, this applies to 71 of 71 residents that reside in the facility. The facility also failed to identify and properly store resident personal care items and perform hand hygiene during incontinence care. This applies to 7 of 7 residents (R1, R30, R40, R44, R52, R53, R169) reviewed for infection control in a sample size of 24. The findings include: 1. On 11/15/23 at 2:16 PM, V11 (Maintenance Director) stated the facility does not regularly test for legionella or other water borne pathogens. Water testing is only done if they have a suspicion there may be an issue. V11 did not provide any documentation for water testing conducted at the facility. […]