Saint Johns on the Lake

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R1) of 1 allegations of abuse or neglect reviewed.*The care plan was delayed in being updated and a key intervention was not added after the investigation was completed. The investigation was not thorough, no like-resident interviews were conducted and the five days of wellness checks facility proposed to monitor R1 after the incident were not completed.Findings include:The Facility Policy and Procedure titled Misconduct last revised 11/2025, documents: Purpose: To provide guidance to assure that all alleged violations involving resident abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are immediately acted upon, reported and investigated in a manner consistent with federal and state regulations to assure resident safety.E. Investigation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting all 20 residents that eat food prepared by the facility. *In the facility's main kitchen, observations of partially used and undated food were observed in the walk-in cooler. Open food was observed in the refrigerator in the resident floor main kitchen with no open or use by date. Findings include: The facility policy and procedure titled Food Storage, dated 5/29/2025 documents: Policy, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free of contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. 14. Refrigerated food storage: . All foods should be covered, labeled and dated. All foods will be checked to assure that foods left quotation mark including leftovers) patient [NAME] will be consumed by their safe use by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 21 residents in the facility. *The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Include the infection preventionist as part of the water management plan committee. - Identify corrective actions when control limits do not meet acceptable ranges of control limits (temperature ranges). *The facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris. Findings include: The facility policy titled Water Management Procedures: Legionella Prevention Procedures issued 5/2024 documents: 1. Water Management Program: a. [Facility name] has developed a water…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based upon observation, interview and record review the facility did not ensure they had a system in place to ensure monitoring of and maintaining of laundry vents that extended up from the laundry room to the outside. This has the potential to effect all 21 Residents residing in the facility. *The facility does not monitor the dryer ventilation going to the outside of the facility from the facility dryers in the basement laundry room to make sure the vent remains clear and free of debris. Findings include: On 6/3/2025, at 9:18 AM, Surveyor toured the basement laundry room with Director of Facilities (DoF)-E and Maintenance Director- F. Surveyor asked about the vent leading from the facility dryers to the outside of the building and how often that is checked. Maintenance Director-F stated they do not check that vent. Surveyor asked if Maintenance Director-F knew where it vented out to. Maintenance Director-F stated somewhere above and on the side. Maintenance Director-F stated that the facility has a company come in to monitor all the vents from the facility to the outside, but does…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure a resident who uses a psychotropic PRN (as needed) drug had an order limited to 14 days for 1 (R6) of 5 residents reviewed for unnecessary medications. R6 had an order for PRN Ativan with a start date of 5/17/2025 and no end date. Findings include: The facility policy and procedure titled, Psychotropic Medication Use and last revised 1/2025, documents, in part: Policy Statement Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior . 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. 4. PRN orders for psychotropic medications are limited to 14 days. 1. For psychotropic medications that are NOT…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure for 1 (R16) of 1 residents reviewed for a level 1 and level 2 PASARR (Preadmission Screening and Resident Review) had the screenings completed as required. *R16 did not have a PASARR level 1 screen completed prior to admission to the facility. A level 1 screen was completed on the day of admission. Additionally, the facility did not ensure a level 2 screen was completed based upon the results of the level 1 screen. Findings include: The facility policy and procedure titled admission Criteria, dated January 2025 documents: policy statement. Our facility admits only resident who's medical and nursing care needs can be met. Policy interpretation and implementation. 9. All the admissions and readmissions are screened for mental disorders, intellectual disabilities or related disorders per the Medicaid preadmission screening and resident review process. 2. If the level I screen indicates that the individual may meet the criteria for a mental disorder,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility did not include 1 (R15) of 2 residents reviewed for antibiotic stewardship on the facility line listing to ensure antibiotic use was monitored per facility protocols and ensure the antibiotic administration was included as part of the overall facility infection prevention and control program. *R15 was receiving an intravenous (IV) Antibiotic (ABT) and was not added to the antibiotic/infection control line list. The line list is part of the antibiotic stewardship program which allows the facility to monitor and track antibiotic use and infections. Findings include: The facility policy and procedure titled Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes, dated January 2025 documents: Policy. Antibiotic usage and outcome data will be collected and documented using a facility approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program based on current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to effect all 21 residents in the facility. *The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: -Include water management team members who were knowledgeable about the facility's water system -Describe the building's water system using text and an accurate flow diagram of the system -Include an assessment of the facility's water system to identify all locations were Legionella could grow and spread -Identify where control measures should be applied based on where Legionella could grow and spread -Identify acceptable ranges of control limits (temperature ranges) and corrective actions when control limits are not met -Include a process to confirm the WMP is being implemented and is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility did not ensure staff working in the kitchen followed standards of practice for proper handling of food while maintaining hand hygiene. This had the potential to effect 8 out of 23 residents who eat food prepared in the main kitchen. Cook-F was observed donning gloves after washing her hands, Cook-F then proceeded to touch menus, contaminating her hands. Cook-F did not change gloves or rewash her hands before proceeding to prepare sandwiches for residents. Findings include: The facility policy, entitled Gloves, Use of bare Hand Contact with Food and Use of Plastic Gloves, dated 11/2018, states: Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Procedure: #3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purposes,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 2 (R6 and R10) residents reviewed for weights. R6 did not have monthly weights done as ordered. R10 did not have weekly weights done as ordered. Findings include: The facility policy titled Clinical Nursing Skills: Weight revised 4/11/11 documents (in part) . .Policy: Residents' weight will remain stable within 3% (percent) of baseline. Purpose: To identify, monitor and implement a plan of care for residents who may be at nutritional risk. Procedure: 1. Resident's weights will be obtained and recorded as follows: - upon admission: Weigh for 4 consecutive weeks to obtain a baseline. - Upon readmission: Weight for 4 consecutive weeks to obtain a baseline. - Upon significant weight loss: Weigh 4 consecutive weeks or until back to baseline. 4. Resident Assistants (RA) will weigh residents according to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure 2 (R6 and R10) of 12 residents had physician orders transcribed correctly. R6 was admitted to the facility on [DATE] and had an order for Tobramycin that was not transcribed correctly and then was not administered as ordered. R10 had an order for an antibiotic that was not transcribed correctly and was given the medication past the prescribed stop date. Findings include: 1.) R6 was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease), hypertensive heart disease and myelodysplastic syndrome. The quarterly MDS (minimum data set) dated 12/13/22 indicates R6 is cognitively intact. The hospital discharge list dated 8/31/22 indicates Tobramycin 300 mg (milligrams)/5 ml (milliliters) nebulizer solution, inhale 5 ml (300 mg total) every 12 hours. Inhale 5 mls via nebulizer BID f(twice daily) or 28 days then stop for 28 days and repeat the cycle. The September 2022 MAR (medication administration record) indicates…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 (R10) residents reviewed. R10 received Levofloxacin (antibiotic) for an excessive duration and without adequate indications for its use. Findings include: The facility policy and procedure titled Antibiotic Stewardship dated 7/2016 documents (in part) . . Policy: (facility) recommends the judicious use of antimicrobial and antibiotic agents to promote optimal clinical outcomes and prevent the development of pathogenic organisms and the emergence of resistance. Procedure: 1. McGeer's criteria will be used to guide physicians and staff to determine if resident symptoms meet the criteria for antibiotic treatment. 2. Basic premises: Residents will not be treated with antibiotics on the basis of a culture result if there are not clinical signs or symptoms supporting an infection. 4. If the nurse receiving the antibiotic order questions the appropriateness of the medication ordered,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 3 of 3 residents (R4, R11 and R124) residing on the unit. The glucometer, which is shared between residents, was not cleaned according to the label instructions. Findings include: The facility policy titled Cleaning and Disinfection of Resident Care Items and Equipment revised 6/2022 documents (in part) . .Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to manufacturer recommendations for disinfection and the OSHA bloodborne pathogens standard. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). 2. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. The Sani-Cloth bleach germicidal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.