Inspection Reports for
St James Living Center
415 SIDNEY ST, SAINT JAMES, MO, 65559-1070
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
191% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
48% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 5
Date: Nov 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, neurological assessments after falls, environmental safety, and catheter care at St James Living Center.
Findings
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.
Deficiencies (5)
Failure to complete baseline care plans within 48 hours of admission for three residents.
Failure to review and revise care plans after falls for five residents.
Failure to document neurological assessments and event reports after falls for six residents.
Failure to ensure safety in the shower room due to an unsecured shower drain cover.
Failure to provide catheter care every shift and to change catheter monthly as ordered for one resident.
Report Facts
Residents affected: 3
Residents affected: 5
Residents affected: 6
Residents affected: 1
Facility census: 43
Missing catheter care documentation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Interviewed regarding baseline care plans, neurological checks, and shower drain safety |
| Care Plan Coordinator | Interviewed regarding responsibility for baseline care plans | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding baseline care plans, care plan updates, neurological checks, and catheter care |
| Administrator | Interviewed regarding baseline care plans, care plan updates, neurological checks, shower drain safety, and catheter care | |
| Certified Medication Technician (CMT) A | Interviewed regarding fall interventions on care plans | |
| Certified Nurse Aide (CNA) C | Interviewed regarding fall interventions on care plans | |
| MDS Coordinator | Interviewed regarding care plan updates after falls | |
| Maintenance Supervisor | Interviewed regarding shower drain cover maintenance | |
| CNA M | Interviewed regarding shower drain cover safety | |
| CNA F | Interviewed regarding shower drain cover safety | |
| RN L | Registered Nurse | Interviewed regarding missed catheter care treatments |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 2
Date: Aug 14, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify a resident's physician after a significant change in condition and administration of Narcan for a suspected overdose, and failure to complete an investigation of the incident.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility staff failed to notify the resident's physician of a significant change in condition and administration of Narcan for suspected overdose.
Facility staff failed to complete an investigation following the resident's overdose incident.
Report Facts
Facility census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Charge Nurse | Responsible for notifying the physician and administering Narcan during the incident |
| Administrator | Interviewed regarding notification and investigation failures | |
| Director of Nursing | DON | Interviewed regarding notification and investigation failures |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where a resident caught fire while smoking with oxygen on, resulting in severe burns.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure a resident remained free from accidents when staff failed to remove oxygen and supervise smoking, resulting in severe burns.
Report Facts
Residents affected: 1
Census: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Assisted resident during fire incident and was educated on smoking safety | |
| Licensed Practical Nurse B | Licensed Practical Nurse | Responded to resident fire incident and provided immediate care |
| Social Service Director | Social Service Director | Responsible for smoking assessments; failed to complete resident's assessment |
| Certified Medication Technician D | Certified Medication Technician | Provided information on smoking assessments and staff awareness |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: May 9, 2025
Visit Reason
The inspection was conducted due to allegations of medication misappropriation by a Certified Medication Technician (CMT A) involving two residents. The investigation was triggered by a phone-in report from a Certified Nurse Aide (CNA C) alleging theft of medications.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect residents from wrongful use of their medications resulting in misappropriation by staff.
Report Facts
Residents affected: 2
Medication doses misappropriated: 12
Facility census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in medication misappropriation findings and terminated for multiple offenses. |
| CNA C | Certified Nurse Aide | Reported evidence of medication theft by CMT A. |
| Business Office Manager | Contacted administrator regarding the medication theft report and participated in investigation. | |
| Director of Nursing | DON | Conducted narcotics count and investigation following the complaint. |
| Administrator | Notified of the complaint, conducted review, suspended and terminated CMT A, and notified authorities. |
Inspection Report
Routine
Census: 48
Deficiencies: 9
Date: Jul 17, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident environment, care planning, nursing staffing, infection control, and other aspects of facility operations.
Findings
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.
Deficiencies (9)
Failure to maintain walls, floors, windows, showers, and equipment in resident rooms clean and in good repair; presence of pests.
Failure to notify residents or representatives in writing of bed hold policy prior to transfer for four residents.
Failure to complete Significant Change in Status Assessment (SCSA) for three residents with significant changes.
Failure to document accurate Minimum Data Set (MDS) assessments for weight loss, restraints, and medication use for three residents.
Failure to update comprehensive care plans for oxygen use, depression, behaviors, wandering, weight loss, and ADL needs for multiple residents.
Failure to provide safe hydraulic lift transfers for two residents due to improper positioning of lift base.
Failure to provide RN coverage for at least eight consecutive hours daily on multiple dates.
Failure to post required nurse staffing information daily and retain staffing records for eighteen months.
Failure to implement infection prevention and control program including use of Enhanced Barrier Precautions during catheter care and proper hand hygiene and glove changes during perineal care for residents; failure to ensure TB screening step one was administered and read prior to hire date for seven employees.
Report Facts
Facility census: 48
Dates with no RN coverage: 14
Residents sampled: 23
Employees with late TB screening: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA E | Certified Nursing Aide | Named in infection control deficiencies related to catheter care and hand hygiene |
| CNA F | Certified Nursing Aide | Named in infection control deficiencies related to perineal care and hand hygiene |
| CNA M | Certified Nursing Aide | Named in infection control deficiencies related to hand hygiene |
| CNA P | Certified Nursing Assistant | Named in TB screening deficiency |
| DA Q | Dietary Aide | Named in TB screening deficiency |
| CMT J | Certified Medication Technician | Named in TB screening deficiency |
| Maintenance Director | Named in TB screening deficiency | |
| Laundry Aide S | Named in TB screening deficiency | |
| Director of Nursing | Director of Nursing | Named in TB screening deficiency and staffing interviews |
| Housekeeper V | Named in TB screening deficiency | |
| CNA E | Certified Nursing Aide | Named in unsafe hydraulic lift transfer observations and interviews |
| CNA F | Certified Nursing Aide | Named in unsafe hydraulic lift transfer observations and interviews |
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 16
Date: Jul 17, 2024
Visit Reason
The inspection was an annual survey of St James Living Center to assess compliance with federal and state regulations regarding resident care, facility maintenance, infection control, and staffing.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, including issues with pest control, maintenance, and environmental conditions. Deficiencies were also noted in resident care assessments, care planning, infection control, staffing, and documentation of bed hold policies and employee records.
Deficiencies (16)
F584 Safe/Clean/Comfortable/Homelike Environment. Facility staff failed to maintain walls, floors, windows, showers, and equipment in resident rooms in good repair and failed to provide an environment free of pests. The facility census was 48.
F625 Notice of Bed Hold Policy Before/Upon Transfer. Facility staff failed to provide written information about the bed hold policy to residents or their representatives prior to transfer for four of 23 sampled residents. The facility census was 48.
F637 Comprehensive Assessment After Significant Change. Facility staff failed to complete a Significant Change Status Assessment for three of 23 sampled residents. The facility census was 48.
F641 Accuracy of Assessments. Facility staff failed to document complete and accurate Minimum Data Set assessments for weight loss, restraints, and medication use for multiple residents. The facility census was 48.
F657 Care Plan Timing and Revision. Facility staff failed to develop and revise comprehensive care plans timely for multiple residents, including assessments of depression, weight loss, and behaviors. The facility census was 48.
F689 Free of Accident Hazards/Supervision/Devices. Facility staff failed to provide safe hydraulic lift transfers for two residents and failed to ensure RN coverage for at least eight consecutive hours daily. The facility census was 48.
F727 Nurse Staffing Information. Facility staff failed to post required nurse staffing information daily and failed to maintain records for 18 months. The facility census was 48.
F732 Posted Nurse Staffing. Facility staff failed to post nurse staffing data in a clear and accessible format and failed to maintain required records. The facility census was 48.
F880 Infection Prevention & Control. Facility staff failed to establish and maintain an infection prevention program, including proper use of Enhanced Barrier Precautions, hand hygiene, and tuberculosis screening. The facility census was 48.
F4031 Communicable Disease-Employees. Facility failed to implement policies to screen employees for communicable diseases. The facility census was 48.
F4033 Employee Hours Documented. Facility failed to maintain written documentation of actual hours worked by employees. The facility census was 48.
F4040 SNF RN-Day Shift, LPN/RN eve/nights. Facility failed to ensure a registered nurse was on duty for at least eight consecutive hours daily. The facility census was 48.
F4074 Protective Oversight, Voluntary Leave. Facility failed to provide twenty-four hour protective oversight and supervision for residents on voluntary leave. The facility census was 48.
F4086 Infection Control/Communicable Disease. Facility failed to use acceptable infection control procedures to prevent spread of infection and failed to report infections timely. The facility census was 48.
F4119 Records Required for Transfer. Facility failed to provide transfer forms including medical history and physician orders when residents were transferred. The facility census was 48.
F6039 Inspect/Rodent Control. Facility failed to minimize presence of rodents, flies, cockroaches, and other insects on premises. The facility census was 48.
Report Facts
Facility census: 48
Sampled residents: 23
Sampled employees: 10
Deficiencies cited: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Freeman | MDS Coordinator | Named in deficiency related to comprehensive assessment after significant change |
| Laundry Aide S | Named in deficiency related to employee file and EDL checks | |
| Certified Nurse Aide (CNA) R | Named in deficiency related to employee file and EDL checks | |
| Director of Nursing (DON) | Director of Nursing | Named in multiple deficiencies related to assessments, staffing, and infection control |
| Certified Medication Technician (CMT) J | Named in deficiency related to employee file and infection control | |
| Certified Nurse Aide (CNA) E | Named in infection control deficiency and hydraulic lift use | |
| Certified Nurse Aide (CNA) F | Named in infection control deficiency and hydraulic lift use | |
| Maintenance Director | Named in deficiency related to employee file and maintenance issues | |
| Administrator | Administrator | Named in plan of correction and interview statements |
Inspection Report
Life Safety
Census: 48
Capacity: 90
Deficiencies: 15
Date: Jul 17, 2024
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety and emergency preparedness regulations at St James Living Center.
Findings
The facility failed to maintain an emergency preparedness communication plan including contact information for the state long-term care ombudsman. Multiple deficiencies were found related to emergency preparedness training, exit door locking mechanisms, emergency lighting, hazardous area enclosures, fire alarm system testing, sprinkler system maintenance, electrical system safety, and oxygen storage safety.
Deficiencies (15)
E031 Emergency Officials Contact Information: The facility failed to develop and maintain an emergency preparedness communication plan including contact information for the state long-term care ombudsman.
E037 EP Training Program: The facility failed to provide emergency preparedness training to all staff upon hire and annually, and failed to maintain documentation of such training.
K222 Egress Doors: The facility failed to maintain exit doors equipped with delayed-egress locking systems that unlock within 15 seconds of manual actuation, potentially delaying evacuation.
K291 Emergency Lighting: The facility failed to conduct monthly functional tests of emergency lighting fixtures, risking equipment failure and delayed evacuation.
K321 Hazardous Areas - Enclosure: The facility failed to ensure doors to hazardous areas were positive latching and self-closing, risking containment of smoke and fire.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to test the fire alarm system monthly and verify signal transmission, risking delayed emergency response.
K353 Sprinkler System - Maintenance and Testing: The facility failed to inspect, test, and maintain the sprinkler system weekly, monthly, and quarterly as required, risking system failure.
K363 Corridor - Doors: The facility failed to maintain fire barrier walls free of openings and ensure doors were smoke tight and positively latched, risking smoke and fire spread.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: The facility failed to maintain fire-rated barrier doors in proper condition, risking containment of smoke and fire.
K712 Fire Drills: The facility failed to conduct fire drills at expected times and document drills properly, risking unpreparedness in emergencies.
K761 Maintenance, Inspection & Testing - Doors: The facility failed to inspect and test fire doors annually and maintain door hardware, risking door malfunction during emergencies.
K911 Electrical Systems - Other: The facility failed to maintain electrical wiring and receptacles in safe condition, risking fire and electrical injury.
K918 Electrical Systems - Essential Electric System: The facility failed to inspect and maintain the emergency generator and electrical systems as required, risking power failure.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to store oxygen and combustible materials safely, risking fire hazards.
K926 Gas Equipment - Qualifications and Training: The facility failed to provide adequate training and education on medical gas safety to staff, risking improper handling and injury.
Report Facts
Facility census: 48
Total capacity: 90
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Date: Nov 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's narcotic medication by a Certified Nurse Assistant (CNA).
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to protect residents from wrongful use of belongings or money, specifically misappropriation of Resident #1's narcotic medication by CNA A.
Failed to ensure oncoming and off-going staff verified and reconciled narcotic counts accurately at each shift change.
Report Facts
Facility census: 53
Narcotic medication count: 30
Dates with missing narcotic count signatures: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Named in misappropriation of narcotic medication finding and termination |
| LPN B | Licensed Practical Nurse | Reported misappropriation, confronted CNA A, and notified ADON |
| ADON | Assistant Director of Nursing | Notified of misappropriation, involved in investigation, and reported incident |
| Administrator | Facility Administrator | Terminated CNA A and involved in investigation |
| Director of Nursing | Director of Nursing | Provided statements about narcotic count procedures and investigation |
| LPN E | Licensed Practical Nurse | Advised staff to contact ADON regarding CNA A's unauthorized medication administration |
| CNA C | Certified Nurse Assistant | Witnessed CNA A's unauthorized access to medication cart and reported concerns |
| CNA F | Certified Nurse Assistant | Reported unusual behavior of CNA A and incidents involving medication cart |
| LPN H | Licensed Practical Nurse | Described narcotic count procedures and expectations |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 4
Date: Nov 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of a resident's narcotic medications by a Certified Nurse Assistant (CNA).
Complaint Details
The complaint investigation substantiated that a CNA misappropriated narcotic medication from Resident #1. The facility conducted an internal investigation, notified police and appropriate agencies, and terminated the CNA involved.
Findings
The facility failed to prevent misappropriation of narcotic medications by a CNA who took medication without authorization. Additionally, the facility failed to ensure accurate narcotic counts and proper documentation by staff at each shift change.
Deficiencies (4)
F602: The resident was not free from misappropriation of narcotic medications as a CNA took medication without authorization and the facility failed to account for missing narcotics. The facility terminated the responsible CNA and notified appropriate authorities.
F658: The facility failed to meet professional standards by not ensuring staff verified and reconciled narcotic counts accurately at each shift change, with multiple undocumented narcotic counts noted.
A4075: The facility did not provide personal attention and nursing care consistent with current acceptable nursing practice as required by regulation.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds, and failed to require reporting of abuse or neglect to appropriate authorities.
Report Facts
Facility census: 53
Narcotic medication count: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Reported missing narcotics and confronted CNA; involved in investigation |
| CNA A | Certified Nurse Assistant | Took narcotic medication without authorization; terminated for misappropriation |
| Administrator | Notified of misappropriation and terminated CNA A | |
| DON | Director of Nursing | Provided statements regarding narcotic count procedures and staff behavior |
| CNA C | Certified Nurse Assistant | Witnessed CNA A's behavior and reported observations |
| LPN E | Licensed Practical Nurse | Involved in questioning staff and reporting incident |
| LPN F | Licensed Practical Nurse | Reported CNA A's suspicious behavior and involvement in narcotic misappropriation |
| CNA F | Certified Nurse Assistant | Reported observations of CNA A's behavior and medication handling |
| LPN H | Licensed Practical Nurse | Reported narcotic count procedures and staff compliance |
Inspection Report
Routine
Census: 55
Deficiencies: 11
Date: Jun 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, care planning, medication management, environmental safety, and infection control.
Findings
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.
Deficiencies (11)
Failed to post the telephone number for the Department of Health and Senior Services Adult Abuse and Neglect Hotline in a form and manner accessible to all residents.
Failed to provide consistent documentation regarding residents' Life-Sustaining Treatment and advance directives for four residents.
Failed to provide a clean, homelike, and comfortable environment due to unclean and damaged flooring in resident rooms.
Failed to provide residents with written responses to grievances and failed to document grievance investigations.
Failed to provide written information to residents or their representatives about the facility's bed hold policy at the time of hospital transfer for five residents.
Failed to develop and implement comprehensive person-centered care plans for four residents, lacking documentation of hospice services, bathing preferences, and medication guidance.
Failed to follow physician orders for catheter size and use, failed to obtain catheter order for one resident, and failed to properly sign out administration of Schedule narcotics for three residents.
Failed to assist four dependent residents with grooming and bathing as per care plans and resident preferences.
Failed to ensure hazardous chemicals were stored safely and shower room doors were locked to prevent resident access.
Failed to store and label medications properly; loose medications found in medication carts.
Failed to implement an effective Antibiotic Stewardship Program including monitoring antibiotic use and conducting antibiotic time-outs.
Report Facts
Facility census: 55
Residents affected: 4
Residents affected: 5
Residents affected: 4
Residents affected: 3
Residents affected: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding hotline posting, grievance process, catheter orders, and medication administration |
| Social Service Director | Social Service Director | Interviewed regarding hotline posting, advance directives, grievance process, and bed hold policy |
| Certified Nurse Aide E | Certified Nurse Aide | Interviewed regarding hotline posting, advanced directives, grievance process, shower assistance |
| Licensed Practical Nurse D | Licensed Practical Nurse | Interviewed regarding hotline posting, catheter orders, narcotic documentation, shower assistance |
| Director of Nursing | Director of Nursing | Interviewed regarding hotline posting, grievance process, catheter orders, care plans, medication administration, shower assistance, hazardous chemical storage, medication destruction, antibiotic stewardship |
| Administrator | Administrator | Interviewed regarding hotline posting, grievance process, shower assistance, hazardous chemical storage, medication destruction, antibiotic stewardship |
| Maintenance Director | Maintenance Director | Interviewed regarding environmental maintenance and hazardous chemical storage |
| Certified Medication Technician A | Certified Medication Technician | Observed and interviewed regarding medication administration and narcotic sign-out |
| Certified Medication Technician B | Certified Medication Technician | Observed and interviewed regarding medication administration and narcotic sign-out |
| MDS Nurse | MDS Nurse | Interviewed regarding care plan development and updates |
| Pharmacist | Pharmacist | Interviewed regarding antibiotic stewardship and medication usage reports |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 11
Date: Jun 2, 2023
Visit Reason
Annual inspection survey conducted on 06/02/2023 to assess compliance with federal and state regulations for St James Living Center.
Findings
The facility was found deficient in multiple areas including required postings, advance directives documentation, safe and homelike environment maintenance, grievance procedures, bed hold policy notifications, comprehensive care planning, medication storage and administration, infection control, and supervision of dependent residents. Several residents' records lacked proper documentation and the facility failed to maintain a clean and safe environment in some areas.
Deficiencies (11)
F575 Required Postings: The facility failed to post the telephone number for the Department of Health and Senior Services Adult Abuse and Neglect Hotline in an accessible manner to all residents.
F578 Request/Refuse/Discontinue Treatment; Formulate Advance Directive: Facility staff failed to provide consistent documentation of residents' life-sustaining treatment wishes for four residents.
F584 Safe/Clean/Comfortable/Homelike Environment: Facility staff failed to maintain a clean, homelike, and comfortable environment; observed debris, urine puddles, and damaged flooring in resident rooms.
F585 Grievances: Facility staff failed to provide residents with a written response to grievances and maintain documentation of grievance investigations.
F625 Notice of Bed Hold Policy Before/Upon Transfer: Facility staff failed to provide written information about the bed hold policy to residents or their representatives at the time of hospital transfer for five residents.
F656 Develop/Implement Comprehensive Care Plan: Facility staff failed to develop and implement comprehensive person-centered care plans for four residents.
F658 Services Provided Meet Professional Standards: Facility staff failed to follow physician orders for catheter care and medication administration for multiple residents.
F677 ADL Care Provided for Dependent Residents: Facility staff failed to assist four of 14 sampled dependent residents with grooming and bathing.
F689 Free of Accident Hazards/Supervision/Devices: Facility staff failed to ensure hazardous chemicals were stored safely and shower room doors were locked to prevent resident access.
F761 Label/Store Drugs and Biologicals: Facility staff failed to store and label medications properly, including loose tablets in medication carts and failure to destroy outdated medications.
F881 Antibiotic Stewardship Program: Facility failed to implement an infection prevention and control program including an antibiotic stewardship program to monitor antibiotic use.
Report Facts
Facility census: 55
Residents with deficient documentation: 4
Residents affected by bed hold policy deficiency: 5
Residents affected by grooming and bathing deficiency: 4
Medication carts observed: 3
Inspection Report
Life Safety
Census: 55
Capacity: 90
Deficiencies: 14
Date: Jun 2, 2023
Visit Reason
The inspection was conducted to assess compliance with life safety code requirements and emergency preparedness regulations at St. James Living Center.
Findings
The facility failed to maintain and update its emergency preparedness plan annually and did not include required names and contact information for staff and volunteers. Multiple life safety deficiencies were found including blocked means of egress, missing exit signs, delayed egress door signage issues, fire alarm panel security lapses, sprinkler system maintenance failures, electrical hazards, and smoking area fire hazards.
Deficiencies (14)
E004 Emergency Plan: Facility staff failed to review and update the emergency preparedness plan at least annually, affecting all occupants.
E030 Names and Contact Information: Facility staff failed to develop and maintain an emergency preparedness plan including names and contact information for all staff and volunteers.
K211 Means of Egress - General: Facility staff failed to maintain means of egress free of obstructions and lacked policies regarding exit signs.
K222 Egress Doors: Delayed egress doors lacked required signage and failed to maintain egress doors free of impediments.
K345 Fire Alarm System - Testing and Maintenance: Facility staff failed to secure the fire alarm control panel against unauthorized access.
K353 Sprinkler System - Maintenance and Testing: Facility staff failed to maintain documentation of 100% inspection and testing of the sprinkler system and failed to maintain sprinklers free of foreign materials.
K363 Corridor - Doors: Facility staff failed to maintain doors in the egress corridor with positive latching hardware and free of obstructions.
K500 Building Services - Other: Facility staff failed to maintain the back and surrounding areas to gas-fired dryers free of lint buildup.
K511 Utilities - Gas and Electric: Facility staff failed to ensure electrical panels had clear working space and failed to maintain electrical cords, outlets, and junction boxes to minimize electrical injury risk.
K914 Electrical Systems - Maintenance and Testing: Facility staff failed to assess electrical receptacles in resident care rooms for physical integrity and continuity of grounding circuit annually.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: Facility staff failed to provide documentation of emergency generator exercising every 36 months.
K923 Gas Equipment - Cylinder and Container Storage: Facility staff failed to store oxygen cylinders properly and failed to secure oxygen tanks in therapy department.
K741 Smoking Regulations: Facility staff failed to maintain designated smoking areas free from fire hazards and failed to properly manage cigarette waste.
K761 Maintenance, Inspection & Testing - Doors: Facility staff failed to maintain nonrated corridor doors to ensure doors latched when closed.
Report Facts
Facility census: 55
Total capacity: 90
Plan of Correction completion date: Jul 16, 2023
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Date: Jan 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify a resident's physician in a timely manner after the resident expired.
Complaint Details
The complaint investigation found the facility failed to notify the resident's physician timely after the resident expired. Interviews with staff and the physician confirmed delayed notification. The complaint was substantiated.
Findings
The facility failed to notify the physician promptly after a resident expired, as evidenced by interviews and record reviews. The facility census at the time was 59 residents.
Deficiencies (2)
F580 Notify of Changes: The facility failed to notify one resident's physician in a timely manner after the resident expired. Staff did not promptly notify Emergency Medical Services, the physician, and the coroner as required.
A4087 19 CSR 30-85.042(78) Dr Notification-Change in Condition: Facility staff did not notify the resident's physician in accordance with emergency treatment policies after a significant change in condition. This deficiency is related to F580.
Report Facts
Facility census: 59
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Date: May 26, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify family members or responsible parties after residents experienced falls.
Complaint Details
The complaint investigation found that staff failed to notify family members or responsible parties of two residents' falls. Interviews with the administrator and review of documentation confirmed the lack of notification. The facility census was 56 at the time of the survey.
Findings
Facility staff failed to notify family members or responsible parties of two residents after falls occurred. Documentation and interviews showed lack of proper notification despite policy requirements.
Deficiencies (2)
F580 Notification of Changes: The facility failed to promptly notify the resident's family or responsible party after an accident or significant change, specifically after two residents experienced falls. Staff did not document notification to family members or responsible parties as required.
A4088 Notify Responsible Party-Change in Condition: Facility staff did not immediately notify the designated person in the resident's record after significant changes or accidents, as evidenced by the F580 deficiency.
Report Facts
Facility census: 56
Inspection Report
Plan of Correction
Census: 50
Deficiencies: 1
Date: May 5, 2022
Visit Reason
The inspection was conducted to investigate allegations of misappropriation and exploitation of resident property at St James Living Center.
Findings
Facility staff failed to prevent misappropriation of money belonging to six residents. The Business Office Manager did not deposit residents' money into their trust accounts, and receipts for cash received were missing or incomplete.
Deficiencies (1)
F602: Facility staff failed to prevent misappropriation of six residents' money when the Business Office Manager did not deposit funds into residents' trust accounts. Receipts and trust account logs did not reflect deposits made by residents' families.
Report Facts
Facility census: 50
Resident funds missing: 200
Resident funds missing: 40
Resident funds missing: 200
Resident funds missing: 5
Resident funds missing: 50
Resident funds missing: 49
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 2
Date: Aug 25, 2021
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide showers or baths to residents when requested.
Complaint Details
The complaint investigation found substantiated issues with residents not receiving showers or baths as requested, leading to dignity and respect violations.
Findings
The facility failed to treat five residents with dignity and respect by not providing showers or baths when requested. Documentation showed residents did not receive showers or baths for multiple weeks, and staff and administration acknowledged the issue without effective resolution.
Deficiencies (2)
F 557 Respect, Dignity/Right to have Personal Property CFR(s): 483.10(e)(2). Facility staff failed to treat five residents with dignity and respect by not providing showers or baths when requested. Shower records showed multiple weeks without documented showers or baths for these residents.
A8030 19 CSR 30-88.010(29) Dignity/Privacy. The regulation was not met as evidenced by the deficiency cited at F557 regarding residents' dignity and privacy.
Report Facts
Residents affected: 5
Facility census: 57
Inspection Report
Routine
Deficiencies: 0
Date: Nov 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 2
Date: Mar 6, 2020
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's grievance process and the development and implementation of comprehensive care plans for residents.
Complaint Details
The complaint investigation found that the facility did not promptly resolve grievances for residents #43 and #314 and failed to maintain grievance documentation for at least three years. The facility also failed to develop adequate care plans for residents #26, #34, and #61.
Findings
The facility failed to make prompt efforts to resolve grievances for two residents and did not maintain evidence demonstrating the results of all grievances for at least three years. Additionally, the facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for three residents.
Deficiencies (2)
F585 Grievances. The facility failed to make prompt efforts to resolve grievances for two residents and did not maintain evidence demonstrating the results of all grievances for at least three years.
F656 Develop/Implement Comprehensive Care Plan. The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for three residents.
Report Facts
Facility census: 67
Residents with unresolved grievances: 2
Residents with incomplete care plans: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in follow-up on grievance policy and care plan implementation |
| Social Service Director | Social Service Director (SSD) | Responsible for grievance program and involved in grievance findings |
| Activity Director | Activity Director (AD) | Coordinates resident council meetings related to grievances |
Inspection Report
Life Safety
Census: 67
Capacity: 90
Deficiencies: 5
Date: Mar 5, 2020
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code, including sprinkler system maintenance, door safety, smoke barrier integrity, smoking regulations, electrical systems, and emergency generator maintenance.
Findings
The facility failed to maintain complete and verifiable monthly inspections and testing of the sprinkler system, ensure doors leading to corridors had positive latching hardware, maintain smoke barrier doors properly, maintain designated smoking areas free from fire hazards, and maintain complete documentation and testing of the emergency generator.
Deficiencies (5)
K353: Facility staff failed to maintain complete and verifiable monthly inspection and testing of the sprinkler system as required by NFPA 25. Missing monthly inspections for several months were not documented.
K363: Doors leading to the corridor did not have positive latching hardware, including a deadbolt lock that did not latch and holes in the employee break room door preventing proper closure.
K374: Facility staff failed to ensure smoke barrier doors were completely closed to resist passage of smoke and fire, including bowed doors creating gaps and failure to maintain proper door operation.
K741: Facility staff failed to maintain designated smoking areas free from fire hazards, including improper disposal of cigarette waste and continuously open cigarette disposal containers.
K918: Facility staff failed to maintain complete and verifiable documentation and testing of the emergency generator, including missing weekly inspections and monthly load test documentation.
Report Facts
Facility census: 67
Facility capacity: 90
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 6, 2019
Visit Reason
Submission of a plan of correction in response to a prior inspection report.
Findings
The document outlines corrective actions planned by the facility to address previously identified deficiencies.
Inspection Report
Life Safety
Census: 73
Capacity: 90
Deficiencies: 12
Date: Feb 6, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations at St James Living Center.
Findings
The facility failed to meet several Life Safety Code requirements including emergency lighting testing, sprinkler system maintenance, fire drills, door inspections, electrical receptacle testing, and gas equipment training. Deficiencies were noted in documentation, testing, and staff knowledge related to fire safety and emergency preparedness.
Deficiencies (12)
K291 Emergency lighting testing was not conducted annually as required, including a 1.5-hour functional test and generator load bank testing. Facility staff were unaware of the testing requirements.
K353 The facility failed to inspect, test, and maintain one wet sprinkler system quarterly as required, lacking documentation for three of four quarterly inspections in 2018.
K712 Fire drills were not conducted quarterly on each shift as required, with missing documentation for several drills and fire condition simulations in 2018.
K761 Facility staff failed to inspect, test, and maintain rated egress doors monthly, lacking documentation and training on door inspections and maintenance.
K914 Electrical receptacles in resident care areas were not assessed for physical integrity, grounding, polarity, and retention force as required, with missing documentation and testing.
K926 Facility staff failed to provide continuing education on safety guidelines and handling of medical gases and cylinders, with incomplete documentation of training and education.
A1132 Night lights in hallways, resident rooms, and toilet rooms were not maintained functional, with 38 of 43 lights not working and no routine schedule for checking.
A1133 Electrical system testing and certification by a qualified electrician was not completed as required by code.
A2034 Sprinkler system inspection, maintenance, and testing were not performed as required, with missing documentation for quarterly testing.
A2050 Emergency lighting system was not tested for sufficient intensity and duration, with missing documentation of tests.
A2061 Fire drill requirements for frequency and unannounced drills were not met, with incomplete documentation.
A4022 Employee orientation and continuing education programs were not fully developed or documented, lacking infection control and emergency protocol training.
Report Facts
Facility census: 73
Total capacity: 90
Number of night lights not functional: 38
Number of fire drills missing documentation: 10
Number of quarterly sprinkler inspections missing: 3
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 4
Date: Jan 19, 2018
Visit Reason
The inspection was the annual survey of St James Living Center to assess compliance with federal regulations and identify deficiencies in resident care and facility safety.
Findings
The facility was found to have multiple deficiencies including unsafe and unsanitary environmental conditions, accident hazards due to unsecured rooms and equipment, inadequate nurse staffing posting, and improper medication storage and labeling. The facility submitted a plan of correction addressing these issues.
Deficiencies (4)
F584 Safe Environment: The facility failed to provide a safe, clean, comfortable, and homelike environment as evidenced by broken drawers, missing baseboards, cracked and peeling storage drawers, broken tiles, and strong odors of urine in resident rooms and restrooms.
F689 Free of Accident Hazards: The facility failed to ensure resident environments were free from accident hazards, including unlocked storage and supply rooms, unsecured medications, and unsafe use of space heaters in resident rooms.
F732 Nurse Staffing Information: The facility failed to post required nurse staffing information daily in an accessible area, including total hours worked and resident census.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure medications were properly stored, labeled, and expired medications discarded, including improper storage in medication rooms and failure to check expiration dates.
Report Facts
Facility census: 75
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justin Atkinson | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Interviewed regarding facility conditions and staffing | |
| Business Office Manager | Interviewed regarding housekeeping concerns | |
| Housekeeper E | Interviewed regarding cleaning schedules and odors | |
| Maintenance Supervisor | Interviewed regarding repairs and maintenance logs | |
| Registered Nurse (RN) B | Interviewed regarding resident room concerns | |
| Certified Nurses Assistant (CNA) F | Interviewed regarding placement of space heater | |
| Certified Nurses Assistant (CNA) G | Interviewed regarding placement of space heater | |
| Licensed Practical Nurse (LPN) A | Interviewed regarding nurse staffing posting | |
| Registered Nurse (RN) C | Interviewed regarding nurse staffing posting and medication room checks |
Inspection Report
Life Safety
Census: 75
Capacity: 90
Deficiencies: 7
Date: Jan 19, 2018
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness and life safety code requirements, including fire safety, sprinkler system maintenance, fire extinguisher installation, smoke barriers, and fire drills.
Findings
The facility failed to meet emergency preparedness communication and training requirements and did not comply with multiple life safety code provisions including fire egress door inspections, sprinkler system maintenance, fire extinguisher installation, smoke barrier integrity, and fire drill documentation.
Deficiencies (7)
E035 Emergency preparedness communication plan was not developed or implemented to share information with residents and families. The facility census was 75 with a capacity of 90.
E036 Emergency preparedness training and testing program was not developed or maintained, lacking documentation of a written program and training completion.
K211 Fire egress doors were not inspected, tested, or maintained annually as required, with missing inspections from January to December 2017.
K353 Sprinkler system was not inspected, tested, or maintained weekly, monthly, and quarterly as required, and lacked documentation of a five-year internal pipe inspection.
K355 Portable fire extinguishers were improperly installed exceeding the maximum height of 5 feet from the floor to the top of the extinguisher.
K372 Smoke barriers were incomplete in five of seven walls, compromising fire resistance and egress safety.
K712 Fire drills were not conducted at various times and under varying conditions as required, with incomplete documentation of drills from January to December 2017.
Report Facts
Facility census: 75
Total capacity: 90
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