St Williams Living Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF700Apr 17, 2025

  Based on observation, interview and document review the facility failed to ensure proper assessment of bed rails for 1 of 4 residents (R1) reviewed for siderails. Staff implemented a new mattress on a bed with side rails attached, resulting in R1's head becoming trapped between the mattress and the side rail of the bed. The immediate jeopardy (IJ) began on 4/10/25, at approximately 12:00 a.m., when facility staff replaced the mattress on R1's bed without checking the entrapment zones between the mattress and the side rail resulting in R1's head becoming trapped between the mattress and the siderail. The IJ was identified on 4/17/25, the administrator was notified of the IJ on 4/17/25, at 4:10 p.m. […]

• Actual harm, isolatedF689Feb 1, 2024

  Based on interview and document review, the facility failed to ensure proper placement of a lift sling for the ceiling (overhead) mechanical lift for 1 of 3 residents (R1) reviewed for accidents. This resulted in harm for R1 when she fell from the mechanical lift and sustained a left rib fracture. This deficient practice is being cited at past non-compliance related to corrective action taken to ensure proper placement of the lift slings when using mechanical lifts prior to the survey. Findings include: R1's annual Minimum Data Set (MDS) dated [DATE] indicated R1 had a severe cognitive impairment, and was totally dependent on staff for all cares and transfers. The MDS indicated R1 had diagnoses of stroke, hemiplegia (one-sided paralysis), vascular dementia, and anxiety. […]

• Actual harm, isolatedF684Jan 8, 2021

  Based on interview and document review, the facility failed to ensure ordered follow up with specialty service physicians and implementation of discharge orders for notification of the surgeon were completed for 1 of 1 residents (R1) following an acute hospitalization for [CONDITION(S)] (heart attack) and post operative coronary artery bypass grafting (CABG). The deficient practice caused actual harm for R1, who required emergent readmission to the hospital and was subsequently diagnosed with shortness of breath, extreme fluid overload, and [CONDITION(S)] (CHF). Findings included: R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF880Dec 11, 2024

  Based on interview and document review, the facility failed to establish an on-going infection control program which included comprehensive surveillance of resident infections including, signs and symptoms of infections, an antibiotic timeout (timeframe used after an antibiotic was initiated to ensure appropriate use and effectiveness) was performed and start/stop dates of antibiotics to prevent the spread of communicable disease and infections. This deficient practice had the potential to affect all 46 residents who resided in the facility. […]

• No harm, potential for more than minimal, patternF812Dec 11, 2024

  Based on observation, interview and document review, food was not served in a sanitary manner for 15 residents who dined in the north dining area, observed during dining services. In addition, the facility failed to maintain the ice machine in a sanitary manner to prevent potential illness for 15 residents who currently received ice from the ice machine in the north dining area. Further, the facility failed to maintain proper holding food temperatures for 13 of 17 residents observed to receive egg salad sandwiches. […]