Sainte Anne Extended Healthcare

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure once opened, a bottle of tuberculin solution (solution used in intradermal skin tests to detect tuberculosis infection) was labeled in accordance to professional standard (an opened multidose vial of tuberculin PPD must be discarded 30 days after the first puncture). Additionally, the facility failed to ensure 1 of 1 resident's (R32) Lantus (insulin glargine) pen was dated once opened.

Inspectors wroteBased on interview and document review, the facility failed to ensure routine dental services were provided or offered to promote oral hygiene and reduce the risk of complication (i.e., further breakdown, oral pain) for 1 of 1 residents (R9) reviewed for dental hygiene and services.

Inspectors wroteBased on interview and document review, the facility failed to ensure routine dental services were provided or offered to promote oral hygiene and reduce the risk of complication (i.e., further breakdown, oral pain) for 1 of 1 residents (R29) reviewed for dental hygiene and services.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure food stored in a unit refrigerator were labeled, dated and discarded properly. Additionally, facility failed to ensure proper food storage for 1 of 1 resident refrigerator that contained undated and unlabeled food. Findings Include:During an observation on 05/20/26 9:05 a.m., the fourth-floor kitchen refrigerator contained the following items: 3 clear sandwich size bags with egg salad sandwiches labeled with room number and undated, 1 small size of uncovered paper bowl of [NAME] tot and a taco wrapped in brown paper from taco [NAME], not labeled and undated. 3 small (2 .25 oz) plastic portion cups, black container, clear covering, holding a creamy and medium consistency substance, not labeled and undated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a dignified dining experience for residents who required assistance with eating. This had the potential to affect all residents in the facility who were dependent on staff for their intake of nutrition.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain separately locked, permanently affixed compartments for storage of controlled drugs for 4 of 4 observed medication storage areas during a facility wide remodel.

Inspectors wroteBased on observations, interview, and document review the facility failed to ensure compression stocking were applied as ordered to help with edema of the lower extremities for 1 of 1 resident (R10) reviewed for activity of daily living .

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure routine grooming was completed who was dependent on staff for personal cares for 1 of 1 resident (R62), reviewed for activities of daily living (ADL)'s .

Inspectors wroteBased on observation, interview and document review, the facility failed to replace and maintain oxygen tubing for 2 of 2 residents (R32 and R65) reviewed for respiratory care.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately clean resident medical equipment after use and place barrier between resident high touch surface and resident multiuse basket. This had the potential to affect all resdient's who received blood glucose monitoring. In addition, the facility failed to ensure proper use of personal protective equipment (PPE) during cares for 1 of 3 residents (R36) reviewed for enhanced barrier precautions (EBP).

Inspectors wroteBased on interview and document review, the facility failed to follow a care planned intervention to prevent or reduce the risk of falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm when R1 fell and sustained a right fibular fracture which required an emergency room (ER) visit. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure proper hand hygiene during personal cares and wound care for 1 of 1 resident (R3) observed for infection control practices.

Inspectors wroteBased on observation, interview and document review the facility failed to provide appropriate care in a timely manner to prevent a decline in condition for 1 of 1 residents (R32) when R32 continued to experience prolonged nausea and decline lasting more than three weeks causing harm. As a result, R32 was sent to the emergency department (ED) and admitted to the intensive care unit (ICU) after the facility failed to ensure the provider was fully appraised of R32's signs and symptoms.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure narcotics were counted in a manner to detect potential diversion at shift change for 2 of 7 medication carts reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were labeled appropriately with open dates. In addition, the facility failed to remove expired medications for 6 of 82 residents (R76, R29, R34, R16, R39) whose medications were observed during medication storage.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure communal vital signs machine was disinfected between resident use for 2 of 2 residents (R61, R71) observed to have vital signs checked conducted without proper disinfection of the machine. This practice had the potential to affect all 26 of 26 resident residing on the floor.

Inspectors wroteBased on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 4 of 5 residents (R13, R17, R31, and R72) over [AGE] years old whose vaccinations histories were reviewed.

Inspectors wroteBased on interview and document review the facility failed to ensure a resident's code status was consistent across the Electronic Medical Record (EMR) and paper chart for one of 10 residents (R46) reviewed for advanced directives.

Inspectors wroteBased on interview and document review the facility failed to fully and accurately complete the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) (Form CMS-10055) for two of three residents (R13 and R64) reviewed for beneficiary notices.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 6.9 % with two errors out of 30 opportunities for error involving 2 of 6 residents (R73, R61)who were observed during the medication pass.

Inspectors wroteBased on interview and document review the facility failed to administer hypoglycemic (low blood sugar) treatments and medications in accordance to physician standing orders for 2 out of 2 residents (R1,R2) reviewed for nursing services.

Inspectors wroteBased on interview, observation and record review, the facility failed to maintain a complete and accurate medical record for 2 of 2 residents (R1, R2) who required hypoglycemic treatment and management.