Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Living Center during CMS and state inspections, most recent first.
Care plans were not reviewed and revised after falls for multiple residents. Five residents with severe cognitive impairment and mobility limitations had documented unwitnessed or witnessed falls, including injuries such as bruising, a femur fracture, and an ER evaluation, but their care plans did not reflect the falls or updated interventions. Staff interviews confirmed that fall interventions should be listed on care plans and that care plans should be updated after each fall.
Incomplete neurological monitoring and missing fall event documentation: Staff did not consistently complete neuro checks or event reports after falls for multiple residents with significant cognitive and mobility impairments. Records showed unwitnessed and witnessed falls with injuries such as facial bruising, skin tears, hematomas, and no apparent injury, yet required post-fall neuro checks were missing or incomplete and event reports were not documented. Interviews confirmed nurses and the DON expected neuro checks and event reports after unwitnessed falls or head involvement, but staff were not consistently following through.
Failure to complete baseline care plans within the required timeframe affected three residents. Record review showed the plans were not completed within 48 hours of admission, despite the facility policy calling for a temporary care plan within 24 hours to meet a new resident’s immediate needs. Staff interviews showed the admitting charge nurse was expected to complete the baseline care plan upon admission so staff would know the resident’s routines and how to provide care.
An unsecured shower drain cover with missing screws created a hazard in a shower room when a resident in a shower chair had a wheel drop into the open drain and the chair tilted forward. Staff said they had noticed the issue and even experienced a shower chair wheel going into the drain before, but they did not report it to maintenance or complete an event report. The DON and administrator stated the hazard should have been reported, and the administrator said the shower room should have been on the monthly maintenance list.
A resident with a suprapubic indwelling catheter and bladder dysfunction did not receive ordered catheter care every shift or the monthly catheter change. Staff failed to document multiple treatments, and observations showed dried drainage at the insertion site with no split gauze in place. The resident said staff did not always provide the care, and the DON, LPN, administrator, and RN acknowledged missed care and documentation issues.
Staff did not notify a resident's physician after the resident was found lethargic and unresponsive, received Narcan for a suspected overdose, and was transferred to the hospital. Despite facility policy requiring physician notification and documentation, the physician was not informed, and there was no record of contact or response.
Facility staff did not initiate an investigation after a resident overdosed on Benzodiazepines and Opiates, received Narcan, and was transferred to the hospital. Despite policy requiring immediate and thorough investigation of such incidents, neither the Administrator nor the DON were fully informed or took action to investigate, resulting in no documentation or analysis of the event.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A Certified Medication Technician misappropriated Lorazepam by signing out and documenting administration to two residents without proper authorization, including after a physician had discontinued the medication for one resident. The CMT falsified records and removed medications that were not present at the time of administration, as discovered through a narcotics count and staff report.
The facility failed to maintain a safe and clean environment, with observations of unclean and poorly maintained areas, including cracked toilet seats, chipped paint, and damaged floors. Residents reported dissatisfaction with unfinished maintenance work and the presence of flies in their rooms. The maintenance director acknowledged a backlog of repairs, but no work orders were submitted for many issues. Additionally, windows in resident rooms were sealed shut, preventing them from being opened.
The facility staff failed to update comprehensive care plans for several residents, leading to deficiencies in care. A resident's care plan did not address oxygen use, despite a physician's order for continuous therapy. Another resident's plan lacked information on a new depression diagnosis and antidepressant use. Other residents had incomplete care plans regarding behaviors, wandering risks, weight loss, and ADL needs. The MDS Coordinator admitted to overlooking these updates, and the DON confirmed the omissions.
Facility staff failed to ensure safe hydraulic lift transfers for two residents by not keeping the lift's base open for stability, as required by policy. Observations showed residents swaying dangerously during transfers, and interviews revealed staff were not properly trained on the lift's operation.
The facility failed to maintain RN coverage for at least eight consecutive hours per day, seven days a week, as required. The Payroll Based Journal report showed multiple days with no RN hours in early 2024. Interviews revealed staffing challenges, with the DON often being the only RN available and working doubles on weekends. The facility did not use agency staff and struggled to hire RNs, despite efforts like job fairs and sign-on bonuses.
Facility staff failed to follow infection control procedures, including Enhanced Barrier Precautions, during resident care. A resident with an indwelling catheter did not receive care with the required gown and gloves. Additionally, two residents did not receive proper hand hygiene and glove changes during perineal care. The facility also failed to comply with its TB control policy, allowing several employees to start work before completing the required PPD test.
Facility staff failed to provide written notification of the bed hold policy to residents or their representatives before hospital transfers. This issue was identified for four residents through interviews and record reviews, which showed a lack of documentation in their medical records. Staff interviews revealed confusion and lack of responsibility regarding the bed hold notification process, with the DON noting previous staff unawareness of the requirement.
Facility staff did not complete Significant Change in Status Assessments (SCSA) for three residents who experienced notable changes in their conditions, including increased assistance needs, cognitive decline, weight loss, and new diagnoses. The MDS Coordinator and DON were unaware of the requirements for conducting these assessments, leading to the oversight.
Facility staff failed to accurately document the MDS for three residents, leading to deficiencies. A resident's significant weight loss was not recorded, another was incorrectly coded for restraint use, and a third was inaccurately documented as receiving hypnotic and anticoagulant medications. The MDS Coordinator admitted to errors and a lack of full training.
The facility failed to post and retain required daily nurse staffing information, including staff numbers and hours worked, for both licensed and unlicensed staff. Observations showed missing or outdated postings, and interviews revealed a lack of awareness from the DON and administrator about these requirements.
Facility staff failed to ensure oncoming and off-going staff members verified and reconciled the narcotic count as accurate at each shift change. A review of the Narcotic Inventory Sheet for October 2023 showed multiple instances where staff did not document or record a signature to signify the count had been completed. Interviews with the Assistant DON, an LPN, and the Administrator confirmed that staff are expected to count narcotics with two nurses every shift and sign the narcotic count sheet.
Facility staff failed to prevent the misappropriation of a resident's narcotic medications when a CNA took the medication without authorization. The incident involved a cognitively intact resident with a diagnosis of pain in the right hip and hypertrophic osteoarthropathy, who was receiving scheduled and as-needed pain medication, including oxycodone 10 mg tablets. The CNA accessed the medication cart, administered the medication without proper authorization, and subsequently fled the facility. The CNA was terminated following an investigation.
Care plans not updated after resident falls
Penalty
Summary
Facility staff failed to review and revise the care plans after falls for five sampled residents. The facility policy titled Care Plan Comprehensive stated that an individualized comprehensive care plan with measurable goals and time frames would be developed based on a thorough assessment, and that the interdisciplinary team was responsible for periodic review and updating when a significant change occurred or when changes affected the resident's care. The survey found that the care plans for Residents #4, #5, #16, #20, and #42 did not contain documentation of subsequent falls or updated interventions after those events. Resident #4 was assessed as severely cognitively impaired, wheelchair dependent, partially to moderately assisted with all mobility, and with diagnoses including arthritis, high blood pressure, heart disease, anxiety, and depression. The medical record documented an unwitnessed fall with bruising to the right side of the face and another unwitnessed fall without injury, but the care plan's falls area had not been updated with those falls or new interventions. Resident #5 was assessed as severely cognitively impaired, wheelchair dependent, dependent for all mobility, with upper extremity impairment on one side and diagnoses including hip fracture, other fracture, high blood pressure, and Alzheimer's disease. The record documented an unwitnessed fall with a left femur fracture and another unwitnessed fall without injury, but the care plan did not reflect those falls or updated interventions. Resident #16 was assessed as severely cognitively impaired, wheelchair dependent, requiring supervision or touch assist with all mobility, and diagnosed with non-traumatic brain dysfunction, cancer, and high blood pressure. The record documented three unwitnessed falls without injury, yet the care plan was not updated to include them. Resident #20 was assessed as severely cognitively impaired, not using mobility devices, requiring supervision or touch assist with walking, with prior falls and diagnoses including heart failure, high blood pressure, anxiety, dementia, and bipolar disorder; the record documented multiple falls, including one with reopening of a right elbow scab, one resulting in an ER evaluation with a bruise to the upper back, and one with a bruise on the back of the head, but the care plan did not document the falls or interventions. Resident #42 was assessed as severely cognitively impaired, using a walker and wheelchair, requiring partial to moderate assist with all mobility, with diagnoses including high blood pressure, diabetes, and Alzheimer's disease; the record documented two unwitnessed falls, including one with bruising to the left eye, and the care plan did not include those events or updated interventions.
Incomplete neurological monitoring and missing fall event documentation
Penalty
Summary
Facility staff failed to consistently complete neurological assessments and event documentation after falls for six sampled residents. The facility policy required an event report for unusual or unexpected events such as falls, and the neurological monitoring form required checks for 72 hours after an unwitnessed fall or head injury. Review of records showed missing neurological checks and missing fall event reports for residents #4, #5, #8, #16, #20, and #42 after multiple falls, including unwitnessed falls and falls with bruising, skin tears, hematomas, or no apparent injury. Resident #4, who was severely cognitively impaired, used a wheelchair, and required partial to moderate assistance with mobility, had two unwitnessed falls. One fall caused bruising to the right side of the face and the other had no injury; the record did not contain neurological checks for the first fall and did not contain nine of 17 checks for the second, and no event reports were documented for either fall. Resident #5, who was severely cognitively impaired, used a wheelchair, had one-sided upper extremity impairment, and was dependent on staff for all mobility, had an unwitnessed fall with a skin tear and another fall with no injury; the record did not contain 11 of 17 neurological checks for the first and eight of 17 for the second. Resident #8, who had moderate cognitive impairment, used a wheelchair, required substantial to maximal assistance for mobility, and had a diagnosis of non-traumatic brain dysfunction, had two unwitnessed falls; the record did not contain seven of 17 neurological checks for one fall and did not contain completed neurological checks for the other, and no event reports were documented. Resident #16, who was severely cognitively impaired, used a wheelchair, required supervision or touch assist with mobility, and had diagnoses including non-traumatic brain dysfunction, cancer, and high blood pressure, had three unwitnessed falls with missing neurological checks. Resident #20, who was severely cognitively impaired and required supervision or touch assist with walking, had multiple falls including unwitnessed falls with skin tears, reopening of a scab, a fall with no apparent injury and ER evaluation, and a witnessed fall with a hematoma to the back of the head; the record lacked neurological checks or had incomplete checks that consisted only of vital signs, and no fall event reports were documented. Resident #42, who was severely cognitively impaired, used a walker and wheelchair, and required partial to moderate assistance with mobility, had two unwitnessed falls; the record did not contain neurological checks for one fall and lacked five of 17 checks for the other, with the completed checks consisting only of vital signs, and no event report was documented for the bruising fall.
Failure to Complete Baseline Care Plans Within Required Timeframe
Penalty
Summary
Facility staff failed to complete a baseline care plan within 48 hours of admission for three residents, identified in the record as Resident #7, Resident #16, and Resident #30, out of 13 sampled residents. The facility policy titled Care Plan, Temporary, stated that a temporary care plan would be implemented to meet a new resident’s immediate needs within 24 hours of admission until the comprehensive assessment and interdisciplinary care plan were completed. Review of the records showed Resident #7’s baseline care plan was completed on 12/20/24, Resident #16’s baseline care plan was completed on 07/21/25, and Resident #30’s baseline care plan was completed on 7/08/25. During interviews, LPN E stated the admitting charge nurse was to complete the baseline care plan within two hours of admission and that it was completed upon admission so staff would know the resident’s normal day-to-day routines and how to care for the resident. The Care Plan Coordinator stated the admitting charge nurse was responsible for the baseline care plans and believed they should be completed 24 to 48 hours after admission. The DON stated baseline care plans should be completed upon admission by the admitting charge nurse and as soon as possible, within 24 hours. The administrator also stated baseline care plans should be completed upon admission and within 24 hours so staff would know how to care for the newly admitted resident.
Unsecured Shower Drain Cover and Unreported Shower Hazard
Penalty
Summary
Facility staff failed to ensure the shower room was free from accident hazards when a metal shower drain cover was left unsecured with three missing screws. The facility's Preventative Maintenance List did not include shower rooms as an area checked during monthly environmental review, and the policies provided did not contain a policy for reporting maintenance concerns and repairs needed. Multiple staff members stated they had noticed the drain cover was not screwed down, but the issue was not reported through a maintenance request or event report before the survey observation. Resident #9's quarterly MDS showed intact cognition, wheelchair use, moderate assist with bathing, and one non-injury fall. The resident stated staff placed him/her in a white plastic shower chair and propelled him/her forward, causing the front wheel of the chair to go into the open drain. The resident said the drain cover flipped up and sent him/her forward in the chair, and he/she had to grab the shower wall bar to avoid falling out of the chair. The resident also stated he/she was afraid to shower until the issue was fixed. Survey observations confirmed the shower drain cover was flipped up and out of the drain, with three missing screws, and the front left wheel of a plastic shower chair was down in the open drain, causing the chair to tilt forward. Staff interviews showed CNA staff had seen the drain cover issue and had also experienced a shower chair wheel going into the drain, but had not reported it to maintenance. The DON and administrator stated they expected staff to report the hazard, complete an event report, and stop using the shower until it was fixed, and the administrator stated the shower room should have been on the monthly maintenance list.
Failure to Provide Ordered Catheter Care and Catheter Change
Penalty
Summary
Facility staff failed to provide ordered care for a resident with a supra-pubic indwelling urinary catheter. The resident had a diagnosis of neuromuscular dysfunction of the bladder, and the care plan and physician’s orders required catheter care every shift, daily cleansing of the suprapubic site with split gauze, and catheter changes monthly on the 18th. Review of the September TAR showed no documentation that catheter care was provided on multiple evening shifts, and there was no documentation that the catheter was changed as ordered on the 18th. Observations showed the catheter site with dried reddish, black, and brown drainage around the insertion site and tubing, and the resident stated staff did not always provide catheter care or place gauze at the site. The DON observed the drainage and lack of split sponge and stated staff were supposed to clean the catheter site. During interviews, the DON, LPN, administrator, and RN acknowledged missing treatments, lack of documentation, and that the catheter was not changed as ordered, with the RN stating he/she ran out of time and did not change the catheter because it did not pop up on the TAR.
Failure to Notify Physician After Resident Overdose and Narcan Administration
Penalty
Summary
Facility staff failed to notify a resident's physician after the resident experienced a significant change in condition, specifically lethargy, pinpoint pupils, and unresponsiveness, which led staff to suspect an overdose and administer Narcan. The resident, who had a history of seizures and was assessed as alert and cognitively intact on the baseline care plan, was subsequently transferred to a local hospital for evaluation. Documentation showed that staff are required to report changes in condition to the DON and physician, and to document any physician contact and response. Despite these requirements, there was no documentation that the physician was notified of the incident. Interviews with the administrator, DON, and the physician confirmed that the physician was not informed, and the physician stated that he was unaware of the overdose and had not adjusted the resident's medications as a result. The charge nurse reported faxing a nonemergent line but did not call the physician, and there was no confirmation that the fax was received. The facility's policy and care plan expectations for physician notification were not followed in this case.
Failure to Investigate Resident Overdose Incident
Penalty
Summary
Facility staff failed to conduct an investigation after a resident experienced an overdose involving Benzodiazepines and Opiates, resulting in the administration of Narcan and subsequent transfer to a hospital. The facility's investigation policy requires prompt and thorough investigation of such incidents, including interviews, assessments, and root cause analysis. However, review of the resident's medical record revealed no documentation of an investigation following the event. The resident, who was alert, cognitively intact, and on chronic opiate therapy for cancer-related pain, was found lethargic, with pinpoint pupils and unresponsive, prompting staff to administer Narcan and call emergency services. Interviews with facility leadership revealed that the Administrator was only partially informed about the incident and did not initiate an investigation due to lack of full details. The DON was not aware of the incident at all and stated that an investigation should have been started to rule out medication errors, the need for medication adjustments, or possible abuse. The absence of an investigation following the overdose event was contrary to the facility's own policy and expectations.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Misappropriation of Resident Medications by CMT
Penalty
Summary
Facility staff failed to prevent the misappropriation of medications for two residents. A Certified Medication Technician (CMT) was found to have signed out and documented the administration of Lorazepam to both residents without proper authorization or, in some cases, after the medication had been discontinued by the physician. For one resident, the CMT continued to sign out and document administration of Lorazepam even after the physician had discontinued the order, and for the other resident, the CMT signed out and documented doses that were not present in the medication cup at the time of administration. These actions were discovered following a report from a Certified Nurse Aide (CNA) who had evidence of the CMT stealing medications, prompting an immediate narcotics count by the Director of Nursing (DON). The review of medication administration records, controlled drug receipt forms, and physician orders revealed discrepancies between the medications signed out and those actually administered or present. The CMT had pre-popped medications and falsified records to indicate administration that did not occur, resulting in the wrongful use and misappropriation of resident medications without consent. Both residents involved had documented needs for or histories of antianxiety medication, with one assessed as moderately cognitively impaired and the other as cognitively intact.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by numerous observations of unclean and poorly maintained areas. Observations included dried stains on walls, cracked and stained toilet seats, dirty bathroom walls, chipped paint, and damaged floors held together with duct tape. Residents expressed dissatisfaction with the unfinished maintenance work, such as incomplete painting and exposed drywall debris. The maintenance director acknowledged a backlog of repairs due to a previous lack of a maintenance director, but no work orders had been submitted for many of the observed issues. Additionally, the facility failed to provide an environment free of pests, as multiple residents were observed with flies in their rooms and on their food. Residents reported the presence of flies to staff, but no effective action was taken to address the issue. The maintenance director and administrator were aware of the flies but had not received reports from staff or taken steps to resolve the problem. The pest control company was contacted but reportedly stated there was nothing they could do. The facility also had issues with sealed windows in resident rooms, which prevented residents from opening them. The maintenance director was aware of the sealed windows, which were closed during the pandemic, but the administrator was not informed of this issue. The lack of a written policy for maintenance and the absence of a system for reporting environmental concerns contributed to the facility's failure to address these deficiencies effectively.
Deficiencies in Comprehensive Care Plan Updates
Penalty
Summary
The facility staff failed to ensure comprehensive care plans were updated for several residents, leading to deficiencies in care. For instance, Resident #2's care plan did not address their oxygen use, despite a physician's order for continuous oxygen therapy. The MDS Coordinator admitted to overlooking this aspect, and the Director of Nursing (DON) confirmed that oxygen use should be included in the care plan. Similarly, Resident #8's care plan lacked information on their new diagnosis of depression and the use of antidepressant medication. The care plan did not include symptoms for staff to monitor or non-pharmacological interventions, nor did it list potential side effects of the medication. The MDS Coordinator acknowledged the oversight, and the DON stated that these elements should have been included in the care plan. Other residents, such as Resident #34, #36, #41, and #45, also had incomplete care plans. Resident #34's care plan did not address their aggressive behaviors, while Resident #36's plan failed to include their wandering and elopement risks. Resident #41's care plan omitted significant weight loss and oxygen use, and Resident #45's plan did not address their ADL needs. In each case, the MDS Coordinator admitted to forgetting to update the care plans, and the DON confirmed that these elements should have been included.
Unsafe Hydraulic Lift Transfers Due to Improper Use
Penalty
Summary
Facility staff failed to provide safe hydraulic lift transfers for two residents, resulting in a deficiency. The facility's policy and the hydraulic lift user manual both require the lift's base to be opened to the maximum width and locked for stability during transfers. However, observations revealed that staff did not adhere to these guidelines. In one instance, two CNAs transferred a resident without keeping the lift's base open, causing the resident to sway dangerously in the sling. The CNAs were unaware of the requirement to keep the lift's legs open for stability, as they had not been trained properly. In another instance, the same CNAs repeated the unsafe practice with a different resident, again closing the lift's legs during the transfer. Interviews with the CNAs revealed a misunderstanding of the lift's operation, with one CNA incorrectly believing that closing the legs was necessary to prevent tripping hazards. The MDS coordinator and the DON confirmed that the lift's legs should remain open during transfers to ensure stability and prevent tipping.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's policies did not include a policy for RN coverage, and the Payroll Based Journal (PBJ) report for Fiscal Year 2024, Quarter 2, showed multiple days with no RN hours. Specific dates in January, February, and March 2024 were identified where the facility did not have an RN present for the required hours. The facility census at the time was 48. Interviews with the Director of Nursing (DON) and the administrator revealed that the facility struggled with RN staffing. The DON, who started in February, was often the only RN available and had to work doubles on weekends. The facility did not use agency nursing staff but relied on corporate RNs to assist when needed. The administrator, who started in May, was unaware of the missing coverage for the quarter and acknowledged the difficulty in hiring RNs, with efforts such as job fairs and sign-on bonuses being implemented to address the issue.
Infection Control and TB Screening Deficiencies
Penalty
Summary
The facility staff failed to adhere to appropriate infection control procedures, specifically Enhanced Barrier Precautions (EBP), during the care of residents. One resident with an indwelling urinary catheter did not receive care with the required gown and gloves, as observed when a Certified Nursing Aide (CNA) provided catheter care without wearing a gown. The CNA was unaware of the EBP requirements, indicating a lack of training or understanding of the infection control measures necessary for residents with indwelling devices. Additionally, staff failed to perform proper hand hygiene and glove changes during perineal care for two residents. Observations showed that CNAs did not change gloves or perform hand hygiene between dirty and clean tasks, increasing the risk of cross-contamination and infection. Interviews with the CNAs revealed an acknowledgment of the need for hand hygiene but highlighted the absence of hand sanitizer in resident rooms, which contributed to the oversight. The facility also did not comply with its Tuberculosis (TB) control policy, as several employees began working before completing the required first step of the purified protein derivative (PPD) test. The Director of Nursing (DON) and the administrator confirmed that the TB tests were not read before the employees' start dates, which is against the facility's policy. This lapse in protocol was attributed to a change in responsibility for TB screenings after the Assistant Director of Nursing (ADON) left the facility.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility staff failed to provide written notification of the bed hold policy to residents or their representatives prior to hospital transfers for four out of 23 sampled residents. This deficiency was identified through interviews and record reviews, revealing that the medical records of these residents lacked documentation of such notifications. The facility's policy on the discharge and transfer of residents mandates that staff explain and provide a copy of the bed hold form to the resident or their representative, which was not adhered to in these cases. Interviews with various staff members, including the Business Office Manager, Director of Nursing, Activities Director, and the Administrator, highlighted a lack of clarity and responsibility regarding the bed hold notification process. The Director of Nursing, who assumed the position in late February, noted that prior staff were unaware of the bed hold requirements. The Administrator mentioned that the nursing staff had not been providing the necessary bed hold forms to residents upon transfer, indicating a systemic issue in the facility's adherence to its own policies.
Failure to Complete Significant Change Assessments for Residents
Penalty
Summary
Facility staff failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for three residents, despite significant changes in their conditions. Resident #2 experienced a decline in functional abilities, including increased assistance needs for daily activities, a fall with injury, and the development of an open lesion on the foot. Resident #8 showed both declines and improvements, such as severe cognitive impairment, increased rejection of care, significant weight loss, and new pressure injuries, along with a new diagnosis of depression and the initiation of antidepressant medication. Resident #41 exhibited changes in behavior, increased assistance needs, significant weight loss, and experienced falls, yet no SCSA was completed for these changes. The MDS Coordinator, responsible for completing significant change assessments, admitted to not being aware of the requirements outlined in the Resident Assessment Instrument (RAI) Manual. The coordinator also mentioned working as a charge nurse at times, which may have contributed to the oversight. The Director of Nursing (DON) also expressed a lack of knowledge regarding the criteria for triggering a significant change MDS. This lack of awareness and understanding among key staff members led to the failure to conduct necessary assessments for residents experiencing significant changes in their health status.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility staff failed to document a complete and accurate Minimum Data Set (MDS) for three residents, leading to deficiencies in the assessment process. For one resident, a significant weight loss from 254 pounds to 228 pounds was not documented as significant on the MDS, despite acknowledgment from the MDS Coordinator and the Director of Nursing (DON) that it should have been. Another resident was incorrectly coded as using limb restraints, although observations and staff interviews confirmed that restraints were never used. The MDS Coordinator admitted to coding restraints due to bed rail use, which was an error, and noted a lack of full training in the position. Additionally, a third resident was inaccurately coded as receiving hypnotic and anticoagulant medications. The MDS Coordinator mistakenly identified amitriptyline as a hypnotic and aspirin as an anticoagulant, indicating a misunderstanding of medication classifications. The MDS Coordinator acknowledged responsibility for ensuring accurate MDS coding but was unaware of the errors. These inaccuracies highlight a failure in the facility's assessment and documentation processes, as outlined in their policy to adhere to CMS guidelines.
Failure to Post and Retain Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff responsible for resident care. The facility also did not retain these records for the required eighteen months. Specific dates were identified where the nurse staffing forms were either not completed or not available, indicating a pattern of non-compliance. Observations on multiple days showed that the daily nurse staff postings were either outdated or missing required information such as shift details and Certified Nurse Aide (CNA) hours. Interviews with the Director of Nursing (DON) and the administrator revealed a lack of awareness and understanding of the requirements for nurse staffing postings. The DON, who took over the responsibility after the Assistant Director of Nursing (ADON) left, admitted to being unaware of the inaccuracies and the failure to save the postings. The administrator, new to the position, was also unaware of the deficiencies in the daily nurse staff postings and was in the process of addressing various operational issues within the facility.
Failure to Verify and Reconcile Narcotic Count at Shift Changes
Penalty
Summary
Facility staff failed to ensure oncoming and off-going staff members verified and reconciled the narcotic count as accurate at each shift change. The facility's Narcotic Count Policy requires that one RN, LPN, or CMT going off duty and one RN, LPN, or CMT coming on duty must count and justify the accuracy of narcotics supply for each individual resident at the change of each shift. However, a review of the Narcotic Inventory Sheet for October 2023 showed multiple instances where staff did not document or record a signature to signify the count had been completed. Specific dates where the count was not documented include all shifts on 10/1/23, 10/7/23, 10/8/23, 10/15/23, 10/28/23, and 10/29/23, among others. This indicates a consistent failure to follow the facility's policy on narcotic counts across multiple shifts and days throughout the month of October 2023. During interviews, the Assistant DON, an LPN, and the Administrator confirmed that staff are expected to count narcotics with two nurses every shift and sign the narcotic count sheet. The DON acknowledged that nurses have developed a bad habit of completing the count but failing to sign the book. The Administrator and DON both expressed the need for in-services with the licensed staff to ensure the counts are completed and signed as required by the facility's policy.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
Facility staff failed to prevent the misappropriation of a resident's narcotic medications when a CNA took the medication without authorization. The facility's Abuse Prohibition Policy defines misappropriation as the wrongful use of a resident's belongings or money without consent. The incident involved a cognitively intact resident with a diagnosis of pain in the right hip and hypertrophic osteoarthropathy, who was receiving scheduled and as-needed pain medication, including oxycodone 10 mg tablets. The resident's medication card of 30 oxycodone pills was found missing, and none of the pills had been signed out as given. The incident was reported by an LPN who noticed the missing medication and confronted the CNA, who claimed to have administered the medication to the resident. The CNA could not produce the medication card and subsequently fled the facility. The ADON and Administrator were notified, and an investigation was initiated. The police, the resident's primary care physician, the appropriate state agency, and the resident's responsible party were informed of the misappropriation. The CNA was terminated for the misappropriation of the resident's narcotic medication. Interviews with various staff members revealed that the CNA had accessed the medication cart and administered the medication without proper authorization. The CNA was reported to have acted suspiciously, moving between bathrooms and eventually fleeing the facility. The staff also noted that the nurses had previously left the keys to the medication cart in a drawer at the nurse's station, which allowed the CNA to access the cart. The facility's investigation confirmed the misappropriation, and the CNA was terminated as a result.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 30 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saint James
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aurora Health And Rehabilitation | 8.3 mi | ★★★★★ | 10 | 0 |
| Rolla Presbyterian Manor | 8.5 mi | ★★★★★ | 0 | 0 |
| Silverstone Place | 9.4 mi | ★★★★★ | 1 | 0 |
| Cedar Pointe | 9.8 mi | ★★★★★ | 0 | 0 |
| Phelps Health | 10.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for St James Living Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.