Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St James Place Nursing Care Center during CMS and state inspections, most recent first.
The facility failed to maintain accurate clinical records for three residents regarding physician-ordered baths/showers. Facility policy required CNAs to document ADL assistance every shift, including baths and showers. For multiple dates over a two-month period, bath logs lacked entries showing that ordered baths/showers were provided. CNAs later reported that at least some of these baths/showers were given but not documented, or could not recall whether care was provided and confirmed they had not charted it. The DON acknowledged that documentation of these baths/showers was missing from the residents’ records on the identified dates.
Ceiling vents in two kitchen areas were found covered with thick, fluffy gray debris above clean dish racks, with no documentation or clear responsibility for cleaning. Staff interviews confirmed the vents were not on a regular cleaning schedule, and 58 residents were potentially affected by meals prepared in these unsanitary conditions.
Nursing staff failed to accurately document a resident's pressure ulcer status, continuing to record the presence of a right heel wound after it had healed, despite clinical records and staff interviews confirming the wound's resolution. The inaccurate documentation persisted in weekly body audits, contrary to accepted professional standards.
A resident with mental health diagnoses was prescribed Risperidone, an antipsychotic, but the MDS assessment was inaccurately coded to indicate no antipsychotic use. Staff confirmed the error during interviews and acknowledged that MDS assessments should accurately reflect all medications received.
A resident receiving hospice care did not have the most recent Hospice Plan of Care in their Hospice Binder, as only an expired plan from a previous certification period was on file. The DON confirmed the absence of current documentation during review.
A resident with an indwelling catheter was observed on multiple occasions with the catheter bag and tubing resting on the floor, contrary to facility policy and the resident's care plan. Staff, including an LPN and the DON, confirmed that the catheter system should not touch the floor to prevent contamination, but this protocol was not followed.
A resident's record lacked documentation of education on pneumococcal and influenza vaccines, as well as the status of vaccine administration, refusal, or contraindication. The DON confirmed incomplete documentation and absence of evidence that the annual immunization process was followed for this resident.
A resident's medical record lacked documentation of COVID-19 vaccine education, consent, or declination, despite the vaccine being available and previously offered. The DON confirmed the absence of required records regarding vaccine education and status for the resident.
The facility failed to maintain accurate records for three residents regarding their bathing schedules. Despite the facility's policy requiring documentation of skilled services and ADL assistance every shift, records showed missing documentation for baths or showers on multiple dates. Interviews with CNAs confirmed that care was provided but not documented, and the DON acknowledged the lack of documentation.
The facility failed to notify the physician and family of significant changes in two residents' conditions. One resident experienced low blood glucose readings and changes in consciousness without physician notification, leading to an Immediate Jeopardy situation. Another resident's family was not informed of a critically low blood glucose reading.
The facility failed to ensure a diabetic resident received appropriate treatment according to the hypoglycemic protocol. Two LPNs did not follow standing orders for low blood glucose levels, did not notify the physician, and did not administer the correct treatment. The resident was found unresponsive and later without a pulse or breath sounds.
The facility failed to ensure that licensed nurses had the necessary competencies to manage hypoglycemia. An LPN did not follow the hypoglycemic protocol when a resident's blood glucose level was 49 mg/dL, and another LPN did not assess the resident's vital signs or notify the physician when the resident was found unresponsive with gurgled breathing. The resident was later found unresponsive, without a pulse or breath sounds.
The facility failed to post the required nurse staffing information on a daily basis at four nurse's stations. Observations revealed missing data on resident census, total number, and actual hours worked for RNs, LPNs, and CNAs on multiple dates. Interviews confirmed the responsible staff did not include the required data, and the administrator was unaware of the posting requirements.
The facility failed to respond to call lights in a timely manner for two residents, resulting in significant delays ranging from 36 to 121 minutes. One resident with Parkinson's Disease and another with a history of falls experienced these delays, which were confirmed by call light logs and resident interviews. The DON acknowledged the issue.
The facility failed to monitor side effects of anticoagulant medications for two residents. One resident with multiple diagnoses, including Metabolic Encephalopathy and Vascular Dementia, had no documentation of monitoring for Xarelto side effects. Another resident with bipolar disorder and a heart condition had no documentation of monitoring for Eliquis side effects. The DON confirmed the lack of monitoring.
The facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications by not ensuring appropriate diagnoses and adequate monitoring for two residents. The Director of Nursing confirmed the inappropriate indications and lack of monitoring documentation for the prescribed medications.
The facility failed to store food according to professional standards, affecting 49 residents. Observations revealed unlabeled and undated food items in various freezers and refrigerators, as well as expired canned goods in the walk-in pantry. Staff confirmed that all stored foods should be labeled, dated, and expired items removed, in accordance with the facility's policy.
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to a resident or her responsible party. The resident's Medicare Part A Skilled Services episode started and ended within the specified dates, and the facility initiated the discharge before benefit days were exhausted. The DON confirmed that a NOMNC was never issued, despite it being required.
A resident with Dementia and other conditions requiring a Hoyer Lift with two staff members for transfers was independently transferred by a CNA without the lift device, contrary to the care plan and physician orders. Interviews with facility staff confirmed the prescribed transfer method was not followed, posing a risk to the resident's safety.
The facility failed to ensure that the oxygen tubing and humidifier bottle for a resident were properly labeled with the date of change, as required by facility policy and physician's orders. Staff confirmed that the equipment should have been labeled, but it was not, indicating a deficiency in the provision of respiratory care.
A hospice CNA was observed performing a bed bath on a resident without wearing a gown, despite the resident being on Enhanced Barrier Precautions. The facility lacked documented evidence of an Enhanced Barrier Precaution Policy, and the Director of Nursing confirmed that the observed practice was inappropriate.
Failure to Accurately Document Ordered Baths/Showers in Clinical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate clinical records for three residents regarding ordered baths/showers, contrary to its own documentation policy and accepted professional standards. The facility’s policy, revised in October 2025, requires documentation every shift for skilled residents and for ADL assistance by CNAs, with records accurately reflecting nursing care and ADL assistance. For Resident #1, physician orders specified baths on Tuesday, Thursday, and Saturday during daytime hours, but the bath log from 12/11/2025 through 01/06/2026 showed no documentation of a bath or shower on multiple ordered dates, including 12/13/2025, 12/16/2025, 12/23/2025, 12/25/2025, and 01/06/2026. A CNA later confirmed that baths were provided on at least two of those dates but were not documented. For Resident #2, physician orders also required baths on Tuesday, Thursday, and Saturday during night hours, yet the bath log from 11/02/2025 through 01/03/2026 contained no documentation of baths or showers on numerous ordered dates. The CNA who worked with this resident on several of the missing dates recalled giving a shower on one of those dates but was unsure if it had been documented, and acknowledged that such care should be recorded. For Resident #3, with similar physician orders for daytime baths on Tuesday, Thursday, and Saturday, the bath log from 11/01/2025 through 01/07/2026 lacked documentation of baths or showers on several ordered dates. The CNA assigned on one of those dates could not remember if the bath was given and confirmed that she did not document it, though she should have. The DON verified that there was no documentation of completed baths or showers for these residents on the identified dates, despite the requirement that such care be recorded.
Failure to Maintain Sanitary Kitchen Ventilation
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen by not ensuring that ceiling vents in two kitchen locations were kept free of thick, fluffy gray debris. Observations revealed that the vent coverings above clean dish racks in both Kitchen A and Kitchen B were covered with excessive amounts of this substance, to the extent that the vent openings were obscured. Multiple staff members, including those responsible for kitchen sanitation and maintenance, were unaware of when the vents were last cleaned or who was responsible for their upkeep. There was no documentation available to indicate that the vents had been cleaned or maintained according to the facility's policy, which requires monthly cleaning and maintenance of ceiling tiles, vents, and lights. The deficiency had the potential to affect 58 residents who received meals prepared in the affected kitchens. Interviews with staff confirmed that the kitchen vents were not included in a regular cleaning or maintenance schedule, and there was no monitoring or documentation of cleaning or replacement of the vent coverings. The lack of adherence to established cleaning protocols and unclear assignment of responsibility contributed directly to the unsanitary conditions observed.
Inaccurate Documentation of Healed Pressure Ulcer
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records in accordance with accepted professional standards for one resident with a history of pressure ulcers. Specifically, nursing staff continued to document the presence of a right heel pressure ulcer in weekly body audits after the wound had been documented as healed. The clinical record showed that the right heel pressure ulcer, initially identified as Stage III, was resolved and wound care was discontinued, yet subsequent weekly body audits by nursing staff inaccurately described the wound as still present and requiring ongoing care. Interviews with facility staff confirmed the inaccuracy of the documentation. The Director of Nursing reviewed the resident's medical record and verified that the right heel pressure ulcer had healed, and any documentation after the healing date indicating the presence of the wound was incorrect. Additionally, a CNA stated that the resident no longer had any pressure injuries on his heels, further confirming the discrepancy between the resident's actual condition and the nursing documentation.
Inaccurate MDS Coding for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's medication status. A review of the clinical record for a resident admitted with diagnoses including bipolar disorder, depression, and anxiety showed that the annual MDS assessment indicated the resident was not receiving antipsychotic medication. However, physician orders documented that the resident was prescribed Risperidone, an antipsychotic, to be administered nightly. During interviews, facility staff confirmed that the MDS was inaccurately coded and acknowledged that all residents' MDS assessments should accurately reflect the medications they receive.
Failure to Maintain Current Hospice Plan of Care Documentation
Penalty
Summary
The facility failed to maintain an up-to-date system for ensuring that a resident's Hospice Binder contained the most recent Hospice Plan of Care. Specifically, for one resident who was admitted to the facility and receiving hospice services from a local agency, the only Plan of Care available in the Hospice Binder was from a previous certification period and had expired. During an interview, the Director of Nursing confirmed that the current Plan of Care was not present in the binder and acknowledged that it should have contained the most recent and up-to-date documentation.
Failure to Maintain Catheter Bag and Tubing Off Floor
Penalty
Summary
The facility failed to implement and maintain an infection prevention and control program as required by policy and resident care plans. Specifically, the facility did not ensure that a resident's indwelling catheter bag and tubing were kept off the floor, as observed on multiple occasions. The facility's policy and the resident's care plan both specified that catheter bags and tubing should not touch the floor to prevent contamination, yet observations on two separate days showed the catheter tubing and bag resting on the floor while the resident was in her room. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the catheter bag and tubing were found on the floor and acknowledged that this was not in accordance with facility policy or infection control standards. The resident involved had a physician's order for Foley catheter care every shift and a care plan approach to prevent the tubing or drainage system from touching the floor, but these measures were not followed during the observed periods.
Failure to Document Immunization Status and Education
Penalty
Summary
The facility failed to ensure that one of five residents reviewed for immunizations had proper documentation regarding education on the benefits and potential side effects of pneumococcal and influenza vaccines, as well as documentation of whether the resident received, refused, or was medically contraindicated for these immunizations. Specifically, the clinical record for this resident did not contain any documentation of pneumococcal and influenza immunization status for the review period. During an interview, the Director of Nursing (DON) confirmed responsibility for the infection control program and acknowledged that the most recent vaccine consent form for the resident was dated several months prior to the review period. The DON also confirmed that there was no evidence that the annual immunization process was followed for this resident, and that documentation of consent, education, and vaccine administration was incomplete.
Failure to Document COVID-19 Vaccine Education and Status
Penalty
Summary
The facility failed to implement its policies and procedures regarding COVID-19 immunizations for one of five residents whose records were reviewed for immunization compliance. Specifically, the medical record for a resident admitted in 2024 did not contain documentation that the resident or their representative received education about the benefits and potential side effects of the COVID-19 vaccine. Additionally, there was no record indicating whether the resident received the COVID-19 vaccine, declined it, or had a medical contraindication. The Director of Nursing confirmed that while COVID-19 vaccines were available and the resident had been offered the vaccine in the previous year, there was no documentation of education, consent, or declination in the resident's file for 2024. This lack of documentation was identified through interviews and record review, and had the potential to affect all residents requiring immunization education and consent.
Failure to Document Resident Bathing Care
Penalty
Summary
The facility failed to maintain accurate records in accordance with accepted professional standards for three residents regarding their bathing schedules. The facility's policy requires documentation of skilled services and assistance with activities of daily living (ADL) every shift. However, the clinical records for three residents showed missing documentation for baths or showers on multiple dates in September 2024. Interviews with CNAs revealed that baths and showers were provided on these dates, but the care was not documented as required. Resident #1's care plan indicated they should be offered a bath of choice at least three days a week, but there was no documentation for several dates. Similarly, Resident #2's care plan also required a bath of choice at least three days a week, yet documentation was missing for multiple dates, including a refusal that was not recorded. Resident #3's care plan had the same requirement, with missing documentation for several dates. The Director of Nursing confirmed the lack of documentation for these residents, acknowledging that it should have been recorded.
Failure to Notify Physician and Family of Significant Changes
Penalty
Summary
The facility failed to ensure nursing staff communicated significant changes in status to the resident's physician or family for two residents. For Resident #48, the nursing staff did not notify the physician after obtaining low blood glucose readings, noting a change in breath sounds, or observing a change in the level of consciousness. Specifically, an LPN administered sugar water to Resident #48 after a blood glucose reading of 49 mg/dL but did not notify the physician. Later, another LPN found Resident #48 unresponsive with gurgled breathing and still did not notify the physician or assess vital signs. Resident #48 was eventually found unresponsive without a pulse or breath sounds. For Resident #46, the nursing staff failed to notify the resident's family after a low blood glucose reading of 24 mg/dL was obtained. The responsible party for Resident #46 confirmed that they were not notified of the low blood sugar event. The DON stated that family should be notified of low blood sugar levels once treatment was provided and the blood sugar was stable, but this protocol was not followed. These deficiencies resulted in an Immediate Jeopardy situation for Resident #48, which was later removed after the facility implemented an acceptable Plan of Removal. However, the deficient practice continued to pose more than minimal harm to the remaining residents in the facility.
Failure to Implement Hypoglycemic Protocol for Diabetic Resident
Penalty
Summary
The facility failed to ensure a resident received treatment and care according to the resident's plan of care and physician's orders. Specifically, two LPNs did not implement the hypoglycemic protocol for a diabetic resident whose blood glucose level was critically low. One LPN administered sugar water instead of following the standing orders, and did not notify the physician of the low readings. The resident's blood glucose level remained low, and the LPN did not recheck it as planned. The second LPN found the resident unresponsive with gurgled breathing but did not assess vital signs or notify the physician, leading to the resident being found unresponsive without a pulse or breath sounds shortly thereafter. The resident involved had a diagnosis of Type 2 Diabetes Mellitus and was at risk for unstable blood sugar levels. The facility's policy required monitoring blood sugar levels as ordered by the physician and notifying the physician of any changes in condition. The hypoglycemic protocol included steps to verify low blood glucose readings, treat them according to specific guidelines, and notify the physician. However, these steps were not followed by the LPNs involved. Interviews with the LPNs and the Director of Nursing confirmed that the hypoglycemic protocol was not followed. The LPNs did not administer the appropriate treatment, such as juice or glucagon, and failed to notify the physician of the resident's condition. The Director of Nursing stated that the hypoglycemic protocol was the standing doctor's orders for diabetic residents and should have been followed. The physician also confirmed that the nurse should have called the on-call physician immediately when the resident's blood glucose reading was critically low.
Failure to Implement Hypoglycemic Protocol
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies and skill sets to care for a resident's needs, specifically in managing hypoglycemia. On the date of the incident, an LPN failed to implement the hypoglycemic protocol when a resident's blood glucose level was 49 mg/dL. Instead of following the protocol, the LPN administered approximately 2 ounces of sugar water via oral swab and did not notify the physician of the low readings. The resident's blood glucose level only increased to 53 mg/dL, and the LPN did not take further appropriate actions or notify the physician as required by the protocol. Another LPN observed the same resident later and found the resident unresponsive with gurgled breathing. Despite these critical signs, the LPN did not assess the resident's vital signs or blood glucose levels and failed to notify the physician. The resident was later found unresponsive, without a pulse or breath sounds. Interviews with the involved staff revealed a lack of knowledge and adherence to the hypoglycemic protocol and the necessity of notifying the physician in such situations. The facility's policies clearly outlined the steps to be taken in the event of hypoglycemia, including verifying blood glucose results, treating according to the protocol, and notifying the physician. However, the involved LPNs did not follow these guidelines, leading to the resident's deteriorating condition and eventual unresponsiveness. The Director of Nursing confirmed that the hypoglycemic protocol was part of the standing doctor's orders and should have been followed by the nursing staff.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information on a daily basis at four nurse's stations. Observations at Nursing Stations a, b, c, and d revealed that the posted staffing data did not include the resident census, the total number, and the actual hours worked for resident care per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants on multiple dates and times. Specific observations were made on 05/28/2024 and 05/29/2024, showing the absence of this critical information at various times throughout the day. Interviews conducted on 05/31/2024 with S8SD and S1ADM confirmed the deficiency. S8SD, who was responsible for posting the staffing assignment sheet, admitted that she did not include the required data. S1ADM, the facility administrator, stated that he was not aware of the specific data that needed to be posted. This lack of awareness and failure to include essential staffing information led to the deficiency noted in the report.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to ensure residents received services with reasonable accommodation of their needs and preferences by not responding to call lights in an appropriate time frame. Resident #27, who has diagnoses including Parkinson's Disease, Muscle Weakness, and Unsteadiness on Feet, experienced significant delays in call light responses, ranging from 37 to 78 minutes. The resident, who has intact cognition, reported waiting up to an hour for a response several times a day. This was confirmed by the call light log and an interview with the resident on 05/28/2024. Similarly, Resident #33, who has diagnoses including Repeated Falls, Personal History of TIA, and CVA, also experienced prolonged call light response times, ranging from 36 to 121 minutes. The resident, who has moderate cognitive impairment, reported waiting more than 30 minutes for a response. The call light log and an interview with the resident on 05/28/2024 confirmed these delays. The Director of Nursing (S2DON) acknowledged that the call light response times were not appropriate and confirmed the findings.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for side effects with the use of anticoagulant medication for two residents. Resident #32, who was admitted with diagnoses including Metabolic Encephalopathy, Cognitive Communication Deficit, Type 2 Diabetes, Vascular Dementia, and Chronic Embolism, had an order for Xarelto 15 mg at dinner for acute embolism. There was no documentation of monitoring for anticoagulant side effects for this resident. Similarly, Resident #250, admitted with diagnoses including bipolar disorder and a heart condition, had an order for Eliquis 5 mg by mouth twice daily for unspecified atrial fibrillation. There was no documentation of monitoring for side effects of Eliquis for this resident. The Director of Nursing confirmed the lack of documentation for both residents and acknowledged that monitoring should have been completed every shift.
Failure to Ensure Appropriate Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications. Specifically, the facility did not ensure that antipsychotic medications were used only when there was an acceptable diagnosis and did not adequately monitor the effectiveness and side effects of psychotropic medications for two residents. Resident #32 was prescribed Clonazepam for Radiculopathy, Quetiapine for Vascular Dementia, and Viibryd for a Depressive Episode. However, there was no documentation of monitoring for target behaviors or side effects of these medications since they were started. Similarly, Resident #250 was prescribed Fluoxetine for Depressive Disorder, Clonazepam for Spondylosis, and Risperdal for Spondylosis, with no documentation of monitoring for target behaviors or side effects provided by the facility. The Director of Nursing confirmed that the diagnoses for which these medications were prescribed were not appropriate indications and acknowledged the lack of monitoring documentation for both residents. An interview with the Director of Nursing revealed that Vascular Dementia was not an appropriate indication for the use of Quetiapine, and Radiculopathy and Spondylosis were not appropriate indications for the use of Clonazepam and Risperdal. The facility failed to provide documentation of monitoring for target behaviors or side effects for the psychotropic medications prescribed to Resident #32 and Resident #250. This lack of appropriate diagnosis and monitoring constitutes a failure to ensure that residents' drug regimens were free from unnecessary psychotropic medications, as required by regulations.
Failure to Store Food According to Professional Standards
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, affecting the 49 residents who were served meals from the kitchen. Observations in Kitchen A revealed five unsealed sausage patties, two uncooked hamburger patties, two pieces of uncooked chicken, two small Styrofoam containers of scooped orange sherbet, and five small glass containers of scooped vanilla ice cream, all unlabeled and not dated in Freezers C and D. Additionally, three bunches of discolored lettuce, two small Styrofoam containers of melted cheese, and two small quart-size containers of tuna salad were found unlabeled and not dated in Refrigerator E. In Kitchen B, five cans of cream of mushroom soup and twenty-three cans of tomato juice were found with expired dates in the walk-in pantry. The main kitchen also had an opened, undated gallon container of salad dressing in the walk-in cooler. Interviews with staff confirmed the findings. S6ESC and S7KM both stated that all stored foods should be labeled and dated once opened, and food with an expired date should be removed and not available for consumption. S1ADM also confirmed that all stored food should be labeled and dated, and food with an expired date should be discarded. The facility's undated policy titled Food Receiving and Storage Policy was reviewed, which stated that all items should be dated and labeled with a received date, and opened items should be dated with an opening date and a use-by date of no more than three days from the opening date. The policy also required the removal of any product that has been opened longer than three days or is past the expiration date.
Failure to Issue Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) to a resident or her responsible party. This deficiency was identified during a review of the SNF Beneficiary Notification Review Form for a resident whose Medicare Part A Skilled Services episode started on 02/08/2024 and ended on 02/28/2024. The facility initiated the discharge from Medicare Part A Services before benefit days were exhausted. An interview with the Director of Nursing (DON) confirmed that a NOMNC was never issued to the resident or her responsible party, despite it being required.
Failure to Use Hoyer Lift for Resident Transfers
Penalty
Summary
The facility failed to ensure a resident received adequate supervision and assistance devices to prevent accidents by not utilizing a Hoyer Lift with the assistance of two staff members for transfers. Resident #28, who had diagnoses including Dementia, Generalized Muscle Weakness, Other Lack of Coordination, and Abnormal Posture, was observed being transferred independently by a CNA without any lift device, despite her care plan and physician orders specifying the need for a Hoyer Lift with two staff members. The CNA confirmed she had never used a Hoyer Lift for Resident #28 and had transferred her independently multiple times, contrary to the care plan and physician orders. Interviews with the LPN, RTD, and DON confirmed that Resident #28 was assessed to need a Hoyer Lift for transfers and that staff should always use the Hoyer Lift with two staff members for her transfers. The facility had clear protocols and care plans in place, but these were not followed by the CNA, leading to the deficiency. The failure to adhere to the prescribed transfer method posed a risk to Resident #28's safety and well-being.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. Specifically, the facility did not ensure that the oxygen tubing and humidifier bottle for Resident #21 were properly labeled with the date of change. Resident #21, who had diagnoses including Chronic Obstructive Pulmonary Disease, Asthma, Atrial Fibrillation, Heart Failure, and Obstructive Sleep Apnea, was observed using an oxygen nasal cannula with a humidifier. However, the oxygen tubing and humidification bottle were not labeled with a date indicating when they were last changed, contrary to the facility's policy and physician's orders which required weekly changes and labeling on Sundays. Interviews with staff members, including an LPN and the Director of Nursing (DON), confirmed that the oxygen tubing and humidification bottle should have been labeled with the date of change. The LPN acknowledged that Resident #21's equipment was not labeled as required, and the DON confirmed that all oxygen tubing and humidifiers should be changed weekly and labeled with the date of change. The facility's failure to adhere to these protocols was identified during the survey, highlighting a deficiency in the provision of respiratory care for Resident #21.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure a Certified Nursing Assistant (CNA) used Personal Protective Equipment (PPE) for a resident on Enhanced Barrier Precautions during a bed bath. Specifically, a hospice CNA was observed performing a bed bath on a resident without wearing a gown, despite the resident having a physician's order for Enhanced Barrier Precautions. The Enhanced Barrier Precaution sign on the resident's door indicated that a gown and gloves should be worn during high-contact activities such as bathing. The facility also lacked documented evidence of an Enhanced Barrier Precaution Policy. The Director of Nursing confirmed that all staff, including hospice staff, should wear a gown and gloves when providing care to residents on Enhanced Barrier Precautions and acknowledged that the observed practice was inappropriate.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Baton Rouge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sage Rehabilitation Hospital Snf | 3.2 mi | ★★★★★ | 0 | 0 |
| Center Point Health Care And Rehab | 3.3 mi | ★★★★★ | 8 | 0 |
| Ollie Steele Burden Manor | 3.4 mi | ★★★★★ | 10 | 0 |
| Sterling Place Healthcare & Rehabilitation Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Mid City Community Nursing And Rehab | 3.6 mi | ★★★★★ | 5 | 0 |
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