St John specialty Care Center

In the surveyor’s words

From the most serious findings on record at St John specialty Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 23, 2023

  Based on review of facility documentation, clinical record, and staff interviews it was determined that the facility failed to provide adequate supervision and effective safety measures to prevent elopement (unauthorized leave from a safe area) of residents with wandering behaviors and/or history of elopement behaviors and failed to ensure resident safety with a staff breakroom left open behind a nurses station. This allowed for Resident R1 and Resident R2 to elope out of the facility without staff knowledge. The facility failed to ensure safety when Resident R1 found a cigarette and lighter in an unlocked staff break room visible behind the nurses station, and was found smoking at the nurses station. […]

• Actual harm, isolatedF600Feb 11, 2026

  Based on review of facility policy and documentation, staff and resident interviews it was determined that the facility failed to protect residents from neglect which resulted in actual harm of multi-system trauma for one of three residents (Resident R1) and transfer to a trauma center hospital.Findings include:Review of facility policy Abuse, Prevention of Resident Abuse, Neglect, Mental Abuse, Reports of Theft, and Misappropriation of Property dated 8/18/25, indicated the facility will provide a safe and secure environment for all residents and will protect a resident's right to be free from any form of abuse, mental abuse, neglect, reports of theft, and misappropriation of resident property.Review of the facility policy Transportation-Competencies and Monitoring dated 8/18/25, indicated… […]

• Actual harm, isolatedF689Feb 11, 2026

  Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to make certain that each resident received adequate supervision and assistance to prevent accidents which resulted in actual harm of multi-system trauma for one of three residents (Resident R1) and transfer to a trauma center hospital. Findings include: Review of the facility policy Resident Accidents/Incidents dated 8/18/25, indicated the facility will provide a safe and secure environment for residents and will be proactive in the prevention of accidents and incidents.Review of the facility policy Reporting a Resident Incident During Transport dated 1/2026, indicated all drivers operating company vehicles will do so in a… […]

• Actual harm, isolatedF689Jul 8, 2022

  Based on review of facility policies, clinical records, and staff interview, it was determined that the facility failed to provide adequate supervision for bed mobility needs for two of three residents (Resident R36 and R50), which resulted in actual harm of Resident R50 causing a fractured humerus(arm bone) and fractured shin(leg bone) and no injury for Resident R36. Facility failed to provide assistance without causing an injury for one of six residents (Resident R65), which resulted in a hand injury. Findings include: Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual effective October 2019, indicated that bed mobility is defined as how resident moves to and from lying position, turns side or side, and positions body while in bed or alternate sleep furniture. […]

• Actual harm, isolatedF600Apr 16, 2021

  Based on a review of facility policy, facility documentation, clinical record review, and staff interview, it was determined that the facility neglected to provide adequate supervision while providing care, when staff turned around, to answer a question by another staff member, resulting in the resident rolling out of bed causing harm in the form of a fracture for one of 6 residents reviewed (Resident R81). Findings include: Review of facility policy, Abuse, Prevention of Resident Abuse, Neglect (Act 28) Mental Abuse, Reports of Theft, Exploitation and Misappropriation of Property, dated 10/7/20, indicated that the facility will provide a safe and secure environment for all residents and will protect a resident's right to be free from . […]