Inspection Reports for
St James Living Center

The facility failed to complete baseline care plans within 48 hours of admission for some residents, did not update care plans after resident falls, failed to document neurological assessments and event reports after falls, had an unsecured shower drain cover posing a safety hazard, and failed to provide timely catheter care and catheter changes as ordered for one resident.

Complaint #2587617 involved failure to notify the physician and failure to conduct an investigation after Resident #1 overdosed on Benzodiazepines and was administered Narcan. The complaint was substantiated based on interviews and record review.

The facility failed to notify the physician when Resident #1 experienced a suspected overdose and was administered Narcan. Additionally, the facility did not conduct a proper investigation into the incident as required by policy. The resident was transferred to the hospital, and the physician was unaware of the incident and had not adjusted medications accordingly.

Complaint #1612565 triggered the investigation. The complaint was substantiated as the resident was found to have smoked with oxygen on, causing injury. The facility failed to complete required smoking assessments and interventions.

The facility failed to ensure the safety of a resident who smoked while using oxygen, leading to severe burns. The resident's smoking assessment was not completed upon admission as required, and staff failed to supervise or prevent the resident from smoking with oxygen on.

The complaint was substantiated. The investigation revealed that CMT A misappropriated at least one Lorazepam 1 mg and eleven Lorazepam 0.5 mg doses. The employee was suspended immediately and terminated on 04/28/25. The facility notified the police and state agency.

The facility failed to prevent the misappropriation of medications for two residents without their consent. The investigation confirmed that CMT A misappropriated multiple doses of Lorazepam, leading to suspension and termination of the employee. The facility took immediate corrective actions including staff in-service and notification of authorities.

The facility was found deficient in maintaining a safe, clean, and homelike environment, providing accurate and complete resident assessments and care plans, ensuring adequate RN staffing, posting nurse staffing information, following infection control protocols including Enhanced Barrier Precautions, and ensuring proper TB screening for employees. Hydraulic lift transfers were also found to be unsafe due to improper use of equipment.

The complaint investigation substantiated that CNA A misappropriated Resident #1's narcotic medication by accessing the medication cart without authorization and administering medication. CNA A fled the facility before police arrival. The facility notified the police, the resident's primary care physician, the state agency, and the resident's responsible party. CNA A was terminated.

The facility failed to prevent the misappropriation of narcotic medication for Resident #1 by CNA A, who administered medication without authorization and subsequently fled the facility. Additionally, the facility failed to ensure proper narcotic counts and signatures at shift changes.

The facility was found deficient in multiple areas including failure to post the Adult Abuse and Neglect Hotline accessibly, inconsistent documentation of residents' advance directives, inadequate cleaning and maintenance of resident rooms, failure to provide written responses to grievances, lack of written notification of bed hold policy at hospital transfer, incomplete care plans, failure to follow physician orders for catheter use, improper narcotic medication sign-out, inadequate assistance with activities of daily living such as bathing, unsafe storage of hazardous chemicals, improper medication storage and labeling, and failure to implement an effective antibiotic stewardship program.