St. Anne's Home

Inspectors wroteBased on interview and record review, the facility failed to designate a registered nurse to serve full-time as the Director of Nurses (DON). The last designated DON ended employment in December, 2022. A waiver from this requirement was not obtained by the facility. The facility has been without a designated DON for 11 months. This failure had the potential to affect the quality of care and outcomes of resident care.

Inspectors wroteBased on observation and interview the facility failed to ensure food was served in a sanitary environment when: 1. Three window screens had gaps, one window screen was missing, and a door screen had a gap. 2. One onion was rotting, and four onions were sprouting in the produce container. 3. A fan over the dishwashing area had grills that were caked with dust. 4. Observation of the pantry found one dented can and one can without a label.

Inspectors wroteBased on observation and interview, facility staff failed to close their garbage dumpster when not being loaded. This failure had the potential to attract pests and rodents.

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program when: 1. A flying insect was seen over the produce bin in the kitchen. 2. An ant was found in the second-floor food service area. Failure to maintain an effective pest control program placed residents at risk for food contamination and food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post a current, daily nurse staffing Assignment Schedule, at each nurse station, for every shift, in a clear and readable format, in a prominent, visible, easily accessible location for residents, visitors, and others. This failure had the potential to cause residents, visitors, and others to have difficulty locating residents or their caregivers at any given time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1). label a refrigerated storage bag containing (64) house supply suppository medications with the correct expiration date. The storage bag of suppositories had an expiration date label of 9/22/23. The suppositories inside the storage bag had an expiration date of 2025. 2). Two Emergency Medication Kit boxes filled with injectable and oral medications had expired medications dated 7/2023 - 11/1/23. 3). Two refrigerated suppository medications had expired dates of 9/22/23 and 10/2023. 4). Three medical supplies had expired dates of 10/2020, 10/21/21, and 10/15/23. These failures had the potential to affect the quality of care and treatment of residents.

Inspectors wroteBased on observation and interview, three kitchen staff were not knowledgeable about the over the hood fire suppressant system. Failure to train kitchen staff upon hire and on a regular basis about all fire suppressant system in the kitchen did not ensure kitchen staff would be able to respond appropriately in the event of a fire within the kitchen.

Inspectors wroteBased on interview and record review, facility staff failed to promptly notify the physician and/or do a more comprehensive assessment for Resident 30, one of three sampled residents who had a fall and complained of pain. Resident 30 had a fall then complained of pain. It took almost 8 hours before staff obtained an x-ray to confirm a right leg fracture.

Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain professional standards for food service safety to ensure safe food handling and storage when: 1. Staff personal belongings were stored in kitchen equipment storage room. 2. Temperature checks log were not completed for the dry storage areas on certain days. 3. Food items stored in kitchen past the use by date (date after which an item should not be used) This deficient practice had the potential to expose residents to food borne illnesses and to affect their appetite due to decreased potency and flavor of expired food items.

Inspectors wroteBased on observation, interview and record review, resident's dignity and self-worth were not maintained and enhanced when one of 12 sampled residents (Resident 41) was assisted to eat lunch by a staff standing up next to his wheelchair. This failure may impact resident's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a person-centered wound care plan for one of 12 sample residents (Resident 5). This deficient practice had the potential to result in Resident 5 not receiving the care and services to meet his needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services for one of 12 sampled residents, Resident 41, to maintain or improve his ability to eat independently. Failure to provide treatment and services is a potential harm risk for residents due to a decline in functioning which negatively impacts their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff competency when meals were not plated in accordance with physicians' order for one of five sampled residents (Resident 38). Failure to ensure standardized procedures may result in decreased nutritional intake leading to weight loss further compromising medical status of residents.

Inspectors wroteBased on observation, interview and record review, for 16 of 16 sampled residents (Residents 27, 1, 36, 193, 6, 31, 30, 24, 3, 20, 18, 17, 41, 22, 13, and 7), the facility failed to: Obtain informed consent prior to the use of bed rails (rails attached to a bed); Review the risks and benefits on the use of bed rails with each resident or resident representative; Assess the resident for risk of entrapment from bed rails prior to installation; and Develop and implement policies and procedures on the use of bed rails. This deficient practice had the potential to put residents at risk for entrapment, fall, or injury. This deficient practice resulted in Substandard Quality of Care (SQC).

Inspectors wroteBased on interview and record review, the facility failed to implement its quality assessment and assurance plan to identify a systemic deficiency, and to develop an action plan when there was no policy and procedure that addressed the specific use of bed rails as enabler for 16 of 16 residents (See F700). Failure to develop a quality assurance plan, not identifying and prioritizing issues and implementing appropriate and necessary corrective actions, had the potential to compromise resident's safety, health and well-being that may lead to injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to established standardized recipes of the residents' Weekly Menu. This failure had the potential for residents not to meet their adequate nutritional needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored according to professional standards when an expired loaf of bread was stored in the kitchen refrigerator. This failure had the potential to result in food borne illnesses. During an initial tour observation of the kitchen and concurrent interview with Staff 16, on 3/18/19, at 9:20 AM, a loaf of bread with expiration date of 3/9/19 was stored in the walk-in refrigerator. Staff 16 verified and acknowledged the findings and stated it (loaf of bread) should be discarded. Review of the facility policy and procedure titled, Date Marking Procedure, dated 3/25/19, indicated, The policy [facility name] utilizes or discards all food products before the UB [use by date] stated by the manufacturer .