St. Annes Nursing Center, St. Annes Residence Inc

Inspectors wroteBased on observations, record review, and interviews, the facility's staff neglected to use a mechanical lift to transfer one (Resident #1) of the three sampled residents who required transfers with a mechanical lift. Staff G, a Certified Nursing Assistant, did not use a mechanical lift as ordered to transfer Resident #1 from the bed to the wheelchair. This deficient practice resulted in Resident #1 sustaining multiple fractures to the right lower extremity. Ninety-three residents in the facility required transfer using a mechanical lift.

Inspectors wroteBased on observations, record review and interviews, the facility failed ensure one (Resident #1) out of three sampled residents received higher level of care and treatment in a timely manner, as evidenced by Resident # 1 who has bilateral contracted upper extremities was noted on 10/24/2025 with swelling to her left arm that progressively got worst with swelling and discoloration throughout the inner portion of the left arm and was no longer contracted. Resident #1 was eventually transferred to a local hospital on [DATE] (two days after changes were noted). Hospital Xray of Resident #1's left arm revealed an acute mid humerus spiral fracture with displacement. There were 197 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to create comprehensive, resident-centered individualized care plans for two (Resident #1 and Resident #4) out of two sampled residents as evidenced by their care plans containing generic interventions not tailored to their specific health needs and functional status.

Inspectors wroteBased on observations records reviewed and interviews, the facility failed to provide adequate supervision and safety measures for two (Resident #1 and Resident #4) out of four sampled residents as evidence by Resident #1 has severe cognitive impairment experienced a fall out of bed due to lack of supervision during personal care, resulting in a head injury. 2)During Resident #4's personal care, staff failed to use fall prevention devices properly, leaving the resident at risk of falling. There were 186 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to accurately the code Minimum Data Set (MDS) for one (Resident #200) out of five sampled residents; as evidenced by the resident was discharged to an Assisted Living Facility, and the MDS was coded to indicate that the resident was discharged to a Short-Term General Hospital.

Inspectors wroteBased on observation, record review and interview, the facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for one (Resident #166) out of 5 residents investigated for Level I PASRR. There were 190 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a fall care plan for two (Resident #25 and Resident #52) out of 13 residents who have orders for floor mats. record review revealed no interventions for floor mats for Resident#25, observations revealed one floor mat in place for Resident#52; and failed to implement a respiratory care plan for one (Resident #95) out of two sampled residents receiving oxygen, as evidenced by Resident #95 oxygen flow rate note in progress at 1.25 Liters Per Minute (LPM) instead of the ordered rate of 2 LPM.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide appropriate treatment and services to prevent Urinary Tract Infection (UTI) for one (Resident #182) out of one resident reviewed for an indwelling urinary catheter, a evidenced by inappropriate placement of the urinary drainage bag anchored on the side rail above the resident's head increasing the risk for UTI and dislodgement.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide appropriate respiratory care consistent with professional standards of practice, for one ( Resident #95) out of two sampled residents receiving oxygen as evidenced by observations of oxygen in progress at 1.25 liters per minute despite a physician's order for 2 liters per minute for Resident #95.

Inspectors wroteBased on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate an effective plan of action was implemented to correct an identified quality deficiency in the problem area related to repeated deficient practice for F 880-Infection Prevention & Control. As evidenced by: F 880 was cited during a Recertification survey ending 11/09/23 when the facility failed to implement infection control procedures for one (Resident #430) as evidenced by Respiratory equipment (Nebulizer and tubing) stored uncovered on bedside table next to a live plant. There were 190 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record review the facility failed to implement infection prevention and control practices and standards for three (Resident #84, Resident #41 and Resident #73) out of seven sampled residents as evidenced by Incentive Spirometer was observed on Resident #84's nightstand bedside with no protective covering. Staff failed to clean the cuff on the vital signs machine between residents. There were 190 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide maintenance/ repair services for wheelchair arm trays for one resident (#88) out of 35 sampled residents as evidenced by Resident(#88) reported armrest in disrepair for two weeks.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement infection control procedures for one (Resident #430) out of 35 sampled residents. As evidenced by Respiratory equipment (Nebulizer and tubing) stored uncovered on bedside table next to a live plant. There were 191 residents residing in the facility at the time of the survey. The Findings Included: During Observation on 11/06/23 at 09:45 AM, Resident #430 was sitting on the side of the bed in the residents room, the Oxygen (02) running at 2 Liters per minute (LPM) via Nasal canula (NC), Resident #430 stated he is waiting on his extra food. The nebulizer mask was stored on the residents bedside table uncovered next to a live plant (Photo Obtained). The 02-tubing with water dated 10/30/23 was stored in bag hanging from the wall. [...]

Inspectors wroteBased on observation, record review and interview, facility failed to follow the menu for pureed diets for the evening meal on 10/26/22. There were 79 residents who were served pureed diets in the facility.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that clean equipment was protected from contamination; clean eating utensils were stored to prevent contamination; Time/Temperature for Safety (TCS) foods were held at proper temperature; and equipment was properly sanitized. This has the potential to affect 179 residents out of 195 residents who consume the facility's food.

Inspectors wroteBased on observation, record review and interview, facility failed to ensure the kitchen dish machine was operating properly and maintaining the proper wash and rinse temperatures. There were 179 residents out of 195 residents who used the facility's eating utensils and dishes.

Inspectors wroteBased on record review and interviews, the facility failed to respond to grievances for one (Resident #545) out of one resident reviewed for grievances. The resident's daughter established communication with the facility concerning complaints about the mother's care and was not informed of the results of the grievances. There were 191 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action for correcting deficiencies resulting in repeated deficient practice. The facility was cited for Food Procurement, Store/Prepare/Serve-Sanitary (F 812) during the survey with exit date of 03/05/ 2020 and again on this recertification survey with exit date of 10/28/2022. This repeated deficient practice has the potential to affect any of the 191 residents residing in the facility at the time of the survey.