Ssm Health Depaul Hospital - Anna House

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided adequate supervision and assistance to prevent accidents for one of three sampled residents (Resident #1) when Certified Nursing Assistant (CNA) C used a Sara lift (also known as a sit to stand, designed to assist individuals with limited mobility in transitioning from a sitting to a standing position) instead of a Hoyer lift (full body lift, used for residents who are unable to move themselves), alone to transfer the resident. CNA C yelled for help. Registered Nurse (RN) A and CNA B responded to the resident's room. The resident was hanging from the Sara lift with his/her legs twisted underneath his/her body, on the platform. A mobile x-ray was ordered. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the main kitchen floors, appliances and food storage areas were clean and free from debris, and that the ceiling was free from dust accumulation. The facility also failed to ensure the [NAME] 2nd floor (A2) dishwashers were in working order, affecting two residents (Resident #24 and Resident #3). The sample was 16. The census was 62. Review of the facility's cleaning rotation policy, undated, showed: -Guideline: Equipment and utensils will be cleaned and sanitized according to the following guidelines, or manufacturer's instructions; - Items cleaned daily: Stove top, grill, kitchen and dining room floors, and exterior of large appliances; - Items cleaned weekly: Storerooms, shelves, and ovens; -Items cleaned monthly: Refrigerators, freezers, and ingredient bins; -Items cleaned annually: Ceilings. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure weekly skin assessments were completed by a nurse for three residents at risk for skin breakdown or with impaired skin integrity (Residents #7, #27, and #32), failed to complete an admission skin assessment and admission note, obtain a admission weight, and obtain skin tear treatment orders (Resident #155), failed to implement the physician order for thromboembolic deterrent (TEDs. a type of compression stocking applied to legs to prevent blood clots) hose when the resident has a history of edema and blood clots, failed to perform skin assessments, failed to obtain monthly weights and address the resident's weight gain (Resident #6), and failed to ensure wound care was being completed (Resident #1). The sample was 16. The census was 62. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate less than 5%. Out of 28 opportunities observed, ten errors occurred, resulting in a 35.71% error rate. (Resident #161, Resident #163 and Resident #162). The census was 62. Review of the facility's Medication Administration policy, dated July, 2021, showed: -Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; -Medication are administered in accordance with written orders of the prescriber; -The resident is always observed after administration to ensure that the dose was completely ingested. Review of the facilities Electronic First dose Kit policy, dated, July, 2021, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided food that was at a safe and appetizing temperature for three residents (Residents #3, #11 and #13). The sample was 16. The census was 62. Review of the facility's checking food temperatures from the main kitchen policy, dated 3/24/24, showed: -Policy statement: the neighborhood team members will check the temperature of hot and cold foods prepared in and delivered from the main kitchen; -Policy interpretation and implementation: upon arrival of the food from the main kitchen, the neighborhood team member will test the temperature of all foods. Hot foods must maintain a temperature of 140 degrees F (Fahrenheit) or greater. Cold foods must maintain a temperature of less than 40 degrees F. The temperatures will be recorded on the food temperature sheet transported with the cart. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and as required by the Centers for Medicare and Medicaid Services (CMS) for residents with central lines to include catheters and wounds requiring treatments (Residents #1, #28, #157 and #155). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were assessed to self-administer medications and to ensure staff adequately supervised residents during medication administration (Residents #28, #7 and #17). The sample was 16. The census was 62. Review of the facility's Medication Administration-General Guidelines policy, dated July 2021, showed: -Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so; -Administration: -Residents can self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications (see Self-Administration of Medications); -The resident is always observed after administration to ensure that the dose was completely ingested. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a significant change in status assessment was completed within 14 days after a determination was made a significant change occurred for one of two residents sampled for hospice (Resident #27). The facility identified six residents who received hospice services. The census was 62. Review of Resident #27's medical record, showed: -admission date 5/1/23; -Diagnoses included neurocognitive disorder with lewy bodies (degenerative brain disorder characterized by dementia, psychosis and features of parkinsonism (movement symptoms)) and dementia; -A hospice admission form, showed the resident admitted to hospice on 7/19/24 with a diagnosis of failure to thrive. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, records, showed: -An annual MDS dated [DATE]; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care needs were met for two dependent residents (Resident #13 and Resident #35). The sample was 16. The census was 62. Review of the facility's activities of daily living policy, dated February 2019, showed: -Policy Statement: the facility will provide care to each resident to ensure that a resident's abilities in activities of daily living do not diminish unless decrease in a resident's function may be expected and unavoidable due to the predictable, cyclical patterns of the resident's clinical condition or the resident or his/her representative's refusal of care and treatment to restore or maintain functional abilities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #32) with limited mobility received appropriate equipment and assistance to maintain mobility when staff failed to ensure the resident had a palm protector as recommended by therapy to address a left hand contracture (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement). The sample was 16. The census was 62. Review of Resident #32's medical record, showed diagnoses included stroke, contracture to left elbow, generalized muscle weakness, dementia and cognitive communication deficit. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/26/24, showed: -Severe cognitive impairment; -Upper extremity impairment on one side; -Dependent for upper body dressing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #1) received proper urinary catheter (tube that drains the urine from the bladder) care after an incontinence episode, staff failed to remove the resident's catheter bag off of the floor after providing care and failed to follow the facility's policy of changing the resident's urinary catheter tubing and bag every 30 days. The sample was 16. The census was 62. Review of the facility's Catheter Care policy, review dated February, 2019, showed: -Policy: To keep indwelling catheter free of vaginal discharge and/or crusting, which can cause infections; -Observation and reporting include: -Color and amount of urine; -Check tubing and drainage for sediment; -Attach Foley (a tube that drains the urine from the bladder) to bed frame only; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory services were provided, consistent with professional standards of practice, for three residents. The facility failed to obtain physician orders for the use of a continuous positive airway pressure (CPAP, a breathing device that delivers air to a mask worn over the nose and mouth) machine for two residents (Residents #3 and #155). The facility also failed to discontinue an order for continuous oxygen use for one resident no longer requiring oxygen therapy (Resident #3) and failed to have physician orders for oxygen for one resident (Resident # 38) who received continuous oxygen. The sample size was 16. The census was 62. Review of the facility's CPAP policy, revision April, 2019, showed it failed to address the requirement of physician orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the room for one resident was adequately equipped with a call light at the resident's bedside (Resident #32). The sample was 16. The census was 62. Review of Resident #32's medical record, showed diagnoses included stroke, contracture (fixed tightening of muscle, tendons, ligaments, or skin, preventing normal movement) to left elbow, dementia, and cognitive communication deficit. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/26/24, showed: -Severe cognitive impairment; -Usually understood-difficulty communicating some words or finishing thoughts but is able to if prompted or given time; -Upper extremity impairment on one side. Review of the resident's care plan, in use at the time of survey, showed: -Need: [...]

Inspectors wroteBased on interview and record review, the facility failed to post nurse staffing information on a daily basis, for two out of four days of survey. The sample was 16. The census was 62. Review of the nurse staffing information on 9/24/24 at 9:00 A.M., 11:13 A.M. and 12:34 P.M., showed the direct care staff daily report was dated 9/23/24. Review of the nurse staffing information on 9/25/24 at 7:26 A.M. and 11:46 A.M., showed the direct care staff daily report was dated 9/23/24. During an interview on 9/26/24 at 11:15 A.M., the Staffing Coordinator said the nurse staffing information has to be posted on a daily basis. She is responsible for doing this, but she was out sick for the past two days. She will try to figure out who will post the staffing information on days she is not in the building. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident with pressure ulcers (injury to the skin and underlying tissues as a result of pressure or friction) received services, consistent with professional standards of practice, when staff failed to enter physician orders for wound care into the medical record for one of four residents sampled, which could have resulted in wound care not being provided. (Resident #1). The census was 60. Review of the facility's Pressure Sore Care Policy, undated, showed: Procedures for Stage 2 (a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough, may also present as an intact or open/ruptured blister) or greater pressure sore: Notify physician of pressure sore for treatment orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that in accordance with acceptable professional standards and practices, medical records maintained were complete and accurately documented for one resident (Resident #1). The sample was five. The census was 60. Review of the facility's job description for Certified Medication Technician (CMT) dated: effective date 7/1/22, showed: -Duties and responsibilities: -Administer prescribed medications to residents; -Pass oral, topical, ophthalmic (having to do with the eyes) and inhalation medications; -Document all medications administered to residents. Review of Resident #1's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 3/16/24, showed: -Moderately impaired cognition; -Diagnoses included: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services by sufficient numbers of nursing personnel on a 24-hour basis to provide nursing care to all residents, when the nurse assigned to [NAME] 1 (A1) was also responsible for oversight of residents in the sister facility 1 (SF1) located in the same building on the first floor and the nurse assigned to [NAME] 2 (A2) was responsible for oversight of residents in the sister facility 2 (SF2) located in the same building on the second floor. The sample was 13. The census was 51. Review of the nursing schedules, dated 5/6/23 through 5/9/23, showed: -5/6/23, shift 10:30 P.M. - 7:00 A.M., nurse scheduled on A1/SF1, nurse scheduled on A2/SF2; -5/7/23, shift 10:30 P.M. - 7:00 A.M., nurse scheduled on A1/SF1, nurse scheduled on A2/SF2; -5/8/23, shift 10:30 P.M. - 7:00 A.M., nurse scheduled on A1/SF1, nurse scheduled on A2/SF2; [...]

Inspectors wroteBased on observation and interview, the facility failed to post the direct care staffing information on a daily basis to include the accurate total number and the actual hours worked for licensed staff, per shift and total facility census. In addition, the staffing sheets maintained by the facility did not include the correct facility name, it included the sister facility's name that is located in the same building. The facility also combined the sister facility's staffing numbers with the facility's staffing numbers. The census was 51. Observation on 5/10/23 at 9:00 A.M., on the first floor, showed the direct care staff daily report, dated 5/9/23, with the sister facility's name listed and no resident census listed. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure there was an air gap between the drain pipe of the ice machine and the floor drain in the main kitchen. The census was 51. Observations on 5/9/23 through 5/11/23 between 8:00 A.M. and 4:00 P.M., of the ice machine located in the main kitchen, showed a plastic tube extended from the back of the ice machine, down to the floor. There was a drain in the floor, in front of the ice machine and the tubing went directly down into the drain. During an interview on 5/11/23 at 9:52 A.M., the Maintenance Director said the tubing was installed wrong. There should be a PVC pipe from the back of the ice machine down to the drain. He has been at the facility for five months and is playing catch up.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow accepted infection prevention and control practices per facility policy when the facility failed to implement their water management program to prevent the spread of waterborne pathogens, such as Legionella. This failure had the potential to affect all residents in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they developed an accurate comprehensive person-centered care plan for each resident, for two of 13 sampled residents (Resident's #1 and #21). The census was 51. 1. Review of the list of residents who received hospice services, provided by the facility, showed Resident #1 not listed. Review of Resident #1's medical record, showed: -Diagnoses included neuromuscular disorder of the bladder (difficulty controlling the bladder) and multiple sclerosis (an autoimmune disease where the body attacks its own nervous system); -No order for an indwelling urinary catheter (a tube inserted through the urinary opening and into the bladder); -No order for hospice services. Review of the resident's care plan, in use at the time of the survey, showed: -Need initiated 4/11/20: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident receives adequate assistance to prevent accidents, for one resident transferred with stand by assistance (Resident's #11). The census was 51. Review of the facility's Gait Belts policy, dated 10/2011, showed: -Purpose: To provide safety of residents and nursing staff members when transferring or ambulating a resident; -Gait belts will be used when transferring or ambulating residents that require the assistance of staff to transfer; -Procedure: Apply gait belt snugly to the resident's waste area. Place hands on belt at back and sides of resident with palms up and fingers on the inside of the belt. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/10/23, showed: -Severe cognitive impairment; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services after an incontinent episode, when staff failed to cleanse all areas of the skin potentially contaminated by urine (Resident #4). For one of two residents observed to receive incontinence care. The census was 51. Review of the facility's Perineal Care (cleansing of the surface area between the thighs, extending from the pubic bone to the tail bone) policy, dated 7/2016, showed: -Purpose: To establish routine practices for providing perineal care which will cleanse, reduce the risk of skin breakdown, infection, and odor; -Residents who are incontinent or who are identified as requiring perineal care will receive care in the morning, every evening, and as needed after urinary incontinence; -Procedure: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 25 opportunities observed, two errors occurred, resulting in an 8% error rate (Residents #1 and #3). The census was 51. 1. Review of Resident #1's medical record, showed: -Diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke; -An order start date of 4/1/20, for Senna Lax (stool softener), give two tablets by mouth two times a day for constipation. Observation on 5/10/23 at 8:50 A.M., showed Licensed Practical Nurse E administered the resident's medications. He/She administered Senna 8.6 milligram (mg) one tablet. 2. Review of Resident #3's medical record, showed: -Diagnoses included dependence on supplemental oxygen; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff followed the facility policy and acceptable professional standards for labeling and discarding insulin vials and eye drops. The facility had three medications carts, two were inspected and problems with insulin were found in one and problems with eye drops were found in both. The census was 47. Review of the facility's insulin storage policy, revised on 2/2019, showed: Purpose: To assure resident medication safety; -Unopened, not-in-use insulin should be stored in a refrigerator at a temperature of 36 - 46 degrees Fahrenheit (F); -Open, in-use insulin may be stored at room temperature below 86 degrees F, unless manufacturer's instructions state otherwise; -Never use insulin beyond the expiration date stamped on the vial, pen, or cartridge that is supplied from the drug manufacturer; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy to complete a prompt and thorough investigation, to ensure interventions are implemented to prevent further incidents, regarding two resident to resident altercations involving two of 12 sampled residents (Residents #9 and #27). The census was 47. Review of the facility's Resident Abuse and Neglect Policy, revised 1/14/17, showed: -Investigating and reporting of abuse and neglect: -The internal reporting procedures are distinct and based on the facility's reporting procedures. The investigation will consist of: -A. An interview with the person(s) reporting the incident; -B. Interviews with any witnesses to the incident; -C. An interview with the resident; -D. A review of the resident's medical record; -E. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff tracked and monitored one resident's pressure ulcers and ensure the resident received treatments as ordered. The facility identified three residents with pressure ulcers, two were sampled and problems were found with one (Resident #140). The census was 47. Review of the resident's admission Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 10/20/19, showed: -admission date of 10/15/19; -Clear speech - distinct intelligible words; -Usually understood; -Understands; -Extensive assistance of one person required for bed mobility and personal hygiene; -Total dependence of two (+) persons required for transfers and walking in room; -Total dependence of one person required for dressing and toilet use; -Wheelchair primary mode of transportation; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document one resident's behaviors (Resident #9). The census was 47. Review of Resident #9's nurse's note, dated 8/6/19 at 8:13 P.M., showed: -New order from the physician to discontinue quetiapine (Seroquel, an anti-psychotic) 25 milligram (mg) by mouth at bedtime; -Increase dose of quetiapine to 50 mg by mouth at bedtime starting 8/6/19; -No documentation regarding the resident's behaviors. Review of the resident's annual Minimal Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/28/19, showed: -Diagnoses of dementia, high blood pressure, anxiety and depression; -Short/long term memory loss; -Verbal behaviors 3 days per week; -Rejects care 4-6 days per week; -Extensive staff assistance for bed mobility, transfers, personal hygiene, dressing, eating and toilet use; [...]

Inspectors wroteBased on interviews, the facility failed to ensure 24 residents received their mail on Saturdays. The census was 47. During an interview on 11/12/19 at 10:00 A.M., three of the five residents attending the meeting belong to the Sisters of Notre Dame. Two of those three Sisters said they do not receive their mail on Saturdays. One Sister who is not a resident, is the power of attorney (POA) for all the the Sisters of Notre Dame who are residents. Their mail goes to the POA, and she delivers the mail Monday through Friday. She is not at the facility on Saturdays so they do not receive their mail on Saturdays. During an interview on 11/13/19 at 11:48 A.M., the Director of Nurses said 24 of the 47 residents are members of the Sisters of Notre Dame. One Sister, who is not a resident, is the POA for all 24 of the Sisters and she delivers their mail. [...]