St Johns Nursing Center

In the surveyor’s words

From the most serious findings on record at St Johns Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF692Sep 21, 2023

  Based on observations, interviews, and record review, the facility failed to identify and provide nutritional interventions in a timely manner to prevent avoidable, severe weight loss for 4 of 7 sampled residents reviewed for nutrition, Residents #138, #42, #363, and #137. The findings included: Review of the facility's policy, titled, Weight Management, dated March 2017, showed, in part, the following: The dietitian or authorized clinical designee, in conjunction with the facility interdisciplinary team (IDT), will monitor and evaluate resident weights for significant changes or other changes that may indicate changing nutritional status. Resident weights will be obtained per facility policy and recorded in the medical record. […]

• Actual harm, isolatedF693Sep 21, 2023

  Based on observations, interviews, and record review, the facility failed to follow physicians' orders regarding tube feeding for 1 of 2 sampled residents, Resident #124. The findings included: Review of the facility's policy, titled, Enteral Nutrition Products, dated 08/22/22, showed in part the following: The facility supplies residents with enteral nutrition support as ordered by the Physician. It further showed that all enteral nutrition products must be labeled with the Resident's name, date it was prepared, product name, concentration, and volume. Resident #124 was admitted to the facility initially on 06/01/23 with diagnoses to include Hyperlipidemia, Dementia, and Left Hip Fracture. […]

• No harm, potential for more than minimal, widespreadF812Mar 3, 2026

  Based on observations and interviews, the facility failed to provide food to residents in a safe and sanitary method. This had the potential to affect 154 residents. The findings included:A tour of the kitchen was conducted on 03/03/26 at 8:50 AM, accompanied by the Kitchen Supervisor upon entering the kitchen. At approximately 9:30 AM, the Kitchen Manager joined the surveyor and the Kitchen Supervisor. At approximately 10:30 AM, the Director of Food and Nutrition Services joined the surveyor, the Kitchen Supervisor, and the Kitchen Manager, on the tour of the kitchen. The following was observed: a. Upon entering the kitchen, a tall gray garbage bin close to the Vulcan stove had an open lid. The staff quickly closed the lid. […]

• No harm, potential for more than minimal, widespreadF812Apr 29, 2021

  Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with profession standards for food service safety, as evidenced by: hair restraints not being worn by dietary staff, maintenance of air-condition ventilation, holding of hot and cold foods at regulatory required temperatures, proper cleaning of the dish machine following each use and pest control prevention. The findings included: 1. During the initial kitchen / food service observation tour conducted on 04/26/21 at 9:00 AM, and accompanied with the Food Service Director (FSD), the following was noted: (a) The breakfast cook was noted to have facial hair / beard and failed to wear a beard protector while preparing and serving foods. […]

• No harm, potential for more than minimal, patternF584Apr 29, 2021

  Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for residents residing of the second, third, and fourth floors. The findings included: During the Environment Tour conducted on 04/28/21 at 1:30 PM with the Director of Environment Services, the following were noted: 1. Second Floor: Room #202 - The bathroom walls , base boards, were in disrepair and required repainting, toilet required re-caulking to the floor, and the portable commode exterior was rusted Room #204 - The exterior of the room entry door was was damaged, privacy curtains (B-bed) were soiled and stained, bathrooms walls were is disrepair and required repainting. […]