St. Ann Health and Rehabilitation Center

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure that quarterly safety evaluations accurately identified and documented the use of elopement-prevention devices, that care plans were developed for residents utilizing wander guards, and that Minimum Data Set (MDS) assessments reflected the presence of these safety devices for three of three residents (Resident (R)3, R8, and R45) reviewed for elopement. As a result of this deficient practice, staff did not recognize wander guards as a safety device to ensure all needed interventions were implemented.re respiratory equipment was stored in a sanitary manner for one of one resident (Resident (R) 15) reviewed for respiratory care out of a total sample of 17. This had the potential to expose the resident to infection.

Inspectors wroteBased on observation, policy review, record review, and interview, the facility failed to ensure that a resident was transferred in a dignified manner for one resident (Resident (R) 24) out of a total of 17 sampled residents reviewed. This failure has the potential to negatively impact a resident's dignity and psychological well-being.

Inspectors wroteBased on observation, staff interview, record review, and the Resident Assessment Instrument (RAI) Manual review, the facility failed to ensure three of three residents (Resident (R) 3, R8, and R45) reviewed for wander guard placement had an accurate Minimum Data Set (MDS) assessment. Failure to code the MDS correctly can lead to inaccurate federal reimbursement and inaccurate assessment and care planning for the residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure a care plan was developed for one of three residents (Resident (R) 3) reviewed for wander guard placement to prevent elopement. This deficient practice increases the risk of inconsistent staff responses and elopement.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure respiratory equipment was stored in a sanitary manner for one of one resident (Resident (R) 15) reviewed for respiratory care out of a total sample of 17. This had the potential to expose the resident to infection.

Inspectors wroteBased on observation, interviews, record review, and policy review, the facility failed to ensure that resident (Resident (R)13) received medications in the correct dosage and as ordered. This resulted in two medication errors out of 32 opportunities, yielding a medication error rate of 6.25%. These errors had the potential to reduce the effectiveness of the prescribed treatment due to underdosing.

Inspectors wroteBased on observation and interviews, the facility did not ensure each resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 2 (R1 and R2) of 3 Residents reviewed for dignity.*On 2/11/26, Surveyor observed Certified Nursing Assistants (CNA) C and D standing, while feeding R1 and R2 their meals. CNA-C was also observed feeding two residents interchangeably at the same time. Findings Include:The facility Meal Supervision and Assistance reviewed/revised 10/29/24 documents:Guideline:.The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes:1. Identifying hazard(s) and risk(s)2. Evaluating and analyzing hazard(s) and risk(s)3. [...]

Inspectors wroteBased on interview, record review, and facility document review, the facility failed to ensure known resident behaviors of kicking, hitting, grabbing, rejection of care, et cetera (etc., other similar things) were addressed, to include the development and implementation of interventions, for 1 (Resident #2) of 5 sampled residents reviewed for behaviors.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food in accordance with professional standards for food service safety for 46 of 48 residents that receive food from the kitchen. * In the facility's main kitchen, observations of partially used and undated food were made in the walk-in and wall freezers/coolers. Several food items were observed in one of the facility's main kitchen wall coolers uncovered open to air and undated. * [NAME] restraints were not being utilized by a kitchen staff working in the main kitchen area. * Temperatures were not completed on all required food items prior to serving the food to residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain 1 (R14) of 12 residents reviewed their right to personal privacy and confidentiality of his or her personal and medical records. * R14's protected health information was left on a computer screen unattended in a common area. R14's medication administration record was displayed on the computer screen in full view of residents and staff that were in and around the common area.

Inspectors wroteBased on interview and record review the facility did not ensure 1 (R12) of 12 residents who were reviewed for a change of condition received a comprehensive assessment. * On 10/6/24, R12 experienced a change in condition and RN (registered nurse)-H did not complete a comprehensive assessment prior to sending R12 to the hospital via ambulance.

Inspectors wroteBased on observation, resident interview, staff interview, and record review, the facility failed to ensure menus were followed and served as posted and on the dietary tray cards. The failure placed any of the 45 facility residents receiving meals from the kitchen at risk of dissatisfaction with their meals.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure adequate supervision and assistance devices were provided to prevent falls for 2 (R3 and R4) of 3 residents reviewed for accidents. * R3 did not have fall interventions in place per care plan to prevent a fall out of bed on 1/24/2024 and fall interventions were observed not to be in place to prevent future falls. * R4 was not transferred as per care plan resulting in a fall on 2/21/2024. R4's care plan indicated R4 required moderate assist of 2 staff members with the use of a sit-to-stand lift. On 2/21/2024, R4 was pivot transferred with the assist of 1 staff member instead of 2 staff members with the use of a sit-to-stand, resulting in R4 being lowered to the ground.

Inspectors wroteBased on observation and interview, the facility did not ensure that drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles, to include the expiration date when applicable for 4 of 10 (R7, R17, R19 and R25) resident insulin's observed. * Residents' insulin, which was open and used, was not dated when opened and insulin was observed to be beyond the expiration date.

Inspectors wroteBased on observation and interview, the facility did not ensure the cleaning and disinfecting of a Glucometer which was being shared between 8 residents. The Glucometer was being disinfected with a 70% isopropyl alcohol wipe rather than with a disinfectant bleach wipe in order to kill blood bourne pathogens. *On 11/9/23 Surveyor observed RN (Registered Nurse)-G administer blood glucose testing for R40. RN-G did not clean and disinfect the facility's shared Glucometer with a disinfectant wipe which kills blood borne pathogens. This deficient practice had the potential to affect 8 residents residing on the 2nd floor who utilize .

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 2 (R40, R20) of 12 residents were provided with personal privacy during medical treatment with the administration of medications (insulin and tear drops) and obtaining testing R40's blood sugar. * On 11/9/23, R40 was not provided with personal privacy during the administration of insulin and when R40's blood sugar was tested while in the dining room. * On 11/9/23, R20 was not provided with personal privacy when her tear drop medication was administered while in the dining room.

Inspectors wroteBased on observation, interviews and record review the facility did not ensure that residents are free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms and document ongoing re-evaluation of the need for restraints for 1 of 1 (R35) residents reviewed for restraints. R35 had a seat belt restraint in use on his wheelchair (w/c). There was no physician's order, careplan, consent or monitoring of the restraint.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 2 (R35) residents reviewed. R35 did not have a rolled up washcloth in his right hand per his care plan and therapy recommendations.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the medication error rate was below 5%. During medication pass, surveyors observed 6 errors out of 32 opportunities with a medication error rate of 18.75%. 3 (R40, R20, and R50) of 6 residents observed during the medication administration task did not receive their medication as ordered. *R40 received their scheduled morning insulin (Humulin and Novolog) after eating 50% of their breakfast. *R20 received their scheduled Omeprazole - extended release reflux medication after eating 25% of their breakfast meal. According to the Assistant Director of Nursing (ADON)-C Omeprazole should be administered on an empty stomach. Surveyor informed ADON-C of observations of RN-G administering Omeprazole after R20 had began eating their breakfast meal. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure residents were free from significant medication errors for 3 (R51, R40 and R20) of 12 residents reviewed for medications. *R51 was admitted to the facility on [DATE] with an order for Augmentin (antibiotic) twice a day until 8/10/23. The facility incorrectly transcribed the order as Augmentin twice a day every 11 days. The incorrect transcription resulted in R51 receiving the Augmentin/antibiotic for two days (or 4 doses) instead of 11 days (or a total of 27 doses). R51's gangrene progressed resulting in a right lower extremity amputation (above the knee amputation). [...]

Inspectors wroteBased on record review and interview, the facility did not notify the resident and the resident's representative of a transfer or discharge in writing that includes the reasons for the transfer and the statement of the resident's appeal rights including the name, mailing address, email address, and telephone number of the entity which receives such requests, and the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman for 5 (R45, R51, R10, R30, and R35) of 5 residents reviewed for discharges. * R45 was transferred to the hospital on 7/20/23. R45 and R45's representative were not provided with a transfer notice. * R51 was transferred to the hospital on 8/21/23. R51 and R51's representative were not provided with a transfer notice. * R10 was transferred to the hospital on 8/24/23. [...]