St Johns Place

In the surveyor’s words

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

• Actual harm, isolatedF600May 20, 2021

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #4) was kept free from abuse and neglect. The resident, who was identified as a fall risk, was left by a nurse in an unoccupied room on an unoccupied hall, with the door shut. The resident was later observed to have injuries to his/her face, presumably from a fall. Additionally, the facility failed to keep Resident #4 safe from abuse when a nurse hit the resident in the head with a binder, grabbed at his/her head, and pulled the resident by the arm. The sample size was 14. […]

• No harm, potential for more than minimal, widespreadF851Dec 9, 2025

  Based on interview and record review, the facility failed to electronically submit to the Center of Medicaid and Medicare Services (CMS) complete and accurate direct care staffing information for Fiscal Year Quarter Three 2025 (April 1 through June 30) and failed to enter nursing hours in the Payroll Based Journal (PBJ) 9/16/25 through 9/30/25. The census was 56. Review of the facility's Reporting Direct-Care Staffing Information (Payroll-Based Journal policy, dated October 2017, showed:-Policy statement: Staffing and census information will be reported electronically to CMS through the PBJ system in compliance with 6106 of the Affordable Care Act;-Direct-care staffing information includes staff hired directly by the facility, those hired through an agency, and contract… […]

• No harm, potential for more than minimal, widespreadF851Mar 20, 2024

  Based on interview and record review, the facility failed to electronically submit to The Center of Medicare and Medicaid services (CMS) complete and accurate direct care staffing information no less frequently than quarterly, for the quarter immediately preceding the annual survey. The census was 45. Review of the facility's Payroll Based Journal (PBJ) staffing Data Report, for fiscal year quarter 1, 2024 ([DATE] through [DATE]), showed the facility triggered for failing to submit data for the quarter. During an interview on [DATE] at 12:24 P.M., the Administrative Assistant and Director of Nursing said PBJ information had not been submitted. The Administrative Assistant said the passwords expired.

• No harm, potential for more than minimal, widespreadF801Jul 28, 2021

  Based on observation, interview, and record review, the facility failed to have a clinically qualified nutritional professional designated as the Food and Nutritional Service Manager for one of one food service kitchen, which prepared food for all residents. This practice potentially affected all of the residents who were served food prepared by the facility. The facility's census was 44. During an observation and interview in the kitchen on 7/22/21 at 9:30 A.M., the Dietary Supervisor (DS) said he/she has worked for the facility for two years, he/she isn't certified, and has never attended classes or received any formal education. Record review of the facility's current employee list, dated 7/20/21, showed a hire date of 1/10/18 for the DS. […]

• No harm, potential for more than minimal, widespreadF725May 20, 2021

  Based on observation, interview and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. (Residents #1, #2, #6, #5, #3). The resident sample was 14. The census was 46. 1. Review of the nursing staff schedule for 3/20/21, showed the following: -7:00 A.M. through 3:00 P.M., one nurse, one certified medication technician (CMT) and three certified nurse aides (CNA) scheduled including nurse aide (NA) E. NA E's name was circled on the schedule; -3:00 P.M. through 11:00 P.M., one nurse, no CMTs and two CNAs, including CNA D. […]