Inspection Reports for
St. James Villas Wellness, Rehab Villas

The facility was found deficient in providing timely incontinence care, following physician orders for wound care, ensuring accurate medication administration, and maintaining safe equipment. Multiple residents were affected by these deficiencies, with issues including delayed incontinence care, improper wound dressing changes, medication errors, and a leaking ice machine posing safety risks.

The investigation was complaint-driven, focusing on catheter care and UTI treatment failures for 4 residents. The complaint was substantiated with findings of inadequate catheter care, failure to follow physician orders, and improper infection control practices.

The facility failed to implement physician's orders for catheter care and monitoring for 4 residents reviewed, resulting in inadequate catheter care, improper cleaning techniques, failure to change catheter bags and tubing when clinically indicated, and missed documentation of urine output. These failures contributed to UTIs and sepsis among residents.

The facility failed to ensure an adequate supply of clean linens, towels, blankets, and washcloths for the residents, affecting all 69 residents. Multiple staff and residents reported shortages, and observations confirmed insufficient linen supplies on various floors and in the laundry area.

The complaint investigation found substantiated failures in notification and care for 1 resident (R1) involving a right heel deep tissue injury and abnormal vital signs related to Covid-19.

The facility failed to notify the POA and physician of a resident's right heel deep tissue injury and elevated heart rate. The resident did not receive proper wound care treatment or timely medical notification, which could have led to infection or sepsis. The resident was transferred to the hospital after deterioration.

The facility failed to provide adequate ADL care, fall prevention interventions, timely incontinent care, and proper catheter care for multiple residents. Observations included residents with poor hygiene, unsafe fall conditions, delayed incontinence care, and improper catheter drainage bag positioning.

The complaint investigation found substantiated deficiencies related to failure to provide written notification of hospital transfers and bed hold policies to residents, their representatives, and the ombudsman. Additional substantiated issues included inadequate ADL care, fall prevention, catheter care, oxygen administration, medication storage, infection control, kitchen sanitation, and call light functionality.

The facility failed to provide written notification to residents, their families, and the ombudsman regarding hospital transfers and bed hold policies for 6 of 6 residents reviewed. Additional deficiencies included inadequate ADL care for dependent residents, failure to implement fall prevention interventions, improper catheter care leading to risk of UTIs, failure to administer oxygen as ordered, improper medication storage without physician orders, poor kitchen sanitation and equipment maintenance, lapses in infection control practices, and malfunctioning resident call light systems.

The complaint investigation found that the facility did not notify the physician or nurse practitioner about resident R1's vomiting and diarrhea episodes on 8/30/24. The complaint was substantiated based on interviews and record review.

The facility failed to notify the physician or nurse practitioner about resident R1's episodes of vomiting and diarrhea on 8/30/2024. Staff interviews and record reviews confirmed no notification was made despite multiple episodes and the facility's notification guidelines.

The complaint investigation found that the facility did not separate COVID-positive residents from COVID-negative or asymptomatic residents due to lack of private rooms and family preferences. The infection preventionist and Director of Nursing confirmed these practices were against guidelines. No documentation was provided to support family preferences.

The facility failed to follow its COVID-19 infection control policy and State Agency guidelines by having COVID-positive residents and asymptomatic or COVID-negative residents sharing rooms, potentially risking an outbreak. Several residents were observed sharing rooms despite differing COVID-19 statuses, and family preferences prevented separation in some cases.

The facility was found deficient in multiple areas including failure to provide adequate personal hygiene assistance, unsafe bed positioning, improper incontinence care, inadequate respiratory equipment storage, unsafe medication storage, infection control lapses, lack of waterborne pathogen testing, and unsafe environmental conditions such as a broken window posing a safety hazard.

The facility failed to ensure that equipment in residents' rooms and bathrooms was maintained in functional and safe order. Specifically, toilet paper holders were missing roll spindles and beds were not functioning properly, with no work orders submitted for repairs.

The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications prior to administration, inadequate assistance with personal hygiene for residents, improper hand hygiene and glove use during incontinence care, failure to provide adaptive equipment to prevent contractures, improper incontinence care increasing risk of urinary tract infections, and failure to provide nutrition supplements and fluid restrictions as ordered.