St. John of God Retirement

In the surveyor’s words

From the most serious findings on record at St. John of God Retirement, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 2, 2023

  Based on observation, interview, and record review the facility failed to provide adequate supervision for one of 29 sampled residents (Resident 92) by failing to: 1. Ensure Resident 92 had a safe room environment free from potential fire hazard and burns when using a candle maker. Resident 92 ordered a candle maker from a store a year ago. Resident 92 was using the candle maker to make candles and soap and with no supervision. The candle maker had the ability to reach high temperatures ranging from 196 - 315 degrees Fahrenheit (a scale of temperature). 2. […]

• Immediate jeopardy, isolatedF684Jun 1, 2021

  Based on observation, interview and record review, the facility failed to ensure that one of one residents (Resident 33), who was drinking alcohol, was provided with the needed care and services by failing to: 1. Ensure Resident 33 who was diagnosed with dementia (progressive impairments to memory, thinking and behavior, that affect the ability to perform everyday activities) was monitored for the consumption of alcohol and the accessibility of the alcohol located at the resident's bedside. 2. Ensure Licensed nurses documented on the Medication Administration Record (MAR) regarding the implementation of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. […]

• Immediate jeopardy, isolatedF756Jun 1, 2021

  Based on observation, interview and record review, the facility failed to ensure one of one sampled residents (Resident 33), who was drinking alcohol, was provided with a thorough drug regimen review. The facility's pharmacist consultant also failed to identify drug irregularities during the monthly Medication Regimen Review (MRR) when antipsychotic ([MEDICATION(S)] [MEDICATION(S)] [medication used to treat [CONDITION(S)]]) medication was used for the treatment of [CONDITION(S)] (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) without a documented clinical rationale for Resident 23 by failing to: 1. […]

• Actual harm, isolatedF689May 22, 2024

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at risk for falls, did not have a fall, by failing to ensure: 1. Staff implemented Resident 1's physician's order which indicated to apply a soft belt (a device that is placed on a person's waist to prevent them from falling out of a bed or a chair) on Resident 1 when up in a wheelchair for safety. 2. Staff followed Resident 1's care plan titled Restraint: Soft belt while up on wheelchair for safety, which indicated to apply a soft belt on the resident while up on a wheelchair for safety, to prevent falls and injuries. 3. […]

• Actual harm, isolatedF689Jan 5, 2024

  Based on interview and record review, the facility failed to provide supervision (an intervention and a means of mitigating accident risk) during walking and toileting for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 falling, sustaining a fracture (broken bone) to the right arm which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1 ' s admission record (face sheet), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including syncope and collapse (fainting), nontraumatic intracranial hemorrhage (bleeding in the brain), and a history of falling. […]