St. Anthony Care Center

Inspectors wroteBased on interview and record review, the facility failed to provide an accurate medication list that included both prescription and over-the-counter medications at the time of discharge to one out of three (Resident 1) reviewed residents. This failure resulted in Resident 1 not receiving prescribed wound care treatment for six days post discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure supplies stored in the medication storage room were appropriate for use when hypodermic needles (devices intended to inject fluids into, or withdraw fluids from, parts of the body below the surface of the skin) were expired. These failures had the potential for residents to receive expired, ineffective, and contaminated medications and treatments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe, sanitary storage and distribution of foods when 1. dates of opened food packages were not labeled. 2. temperatures of prepared foods were not logged that were served to residents for dinners on 10/7/24 and 10//14. These failures had the potential to place all residents getting meals from the kitchen to be at risk for foodborne illness potentially leading to hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. follow proper handwashing/hand hygiene protocol. 2. replace a full sharps container (a puncture resistant container used to safely dispose of sharp medical objects like needles and lancets). The deficient practice had the potential for spread of infection.

Inspectors wroteBased on observation and interview, the facility had five residents' rooms (room [ROOM NUMBER], 2, 4, 5 and 8) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for delivery of care to each of the residents in each room, or for storage of the residents' belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation, food handling, and food storage practices when: 1. Refrigerator 1 had two bags of iceberg lettuce that were discolored, wilted, and did not have received-by or used-by dates. 2. During tray line (serving and plating of food) service: - Pureed (a procedure to change the texture of solid food so that it is smooth with no lumps and has a texture like pudding) fish and pureed rice were watery and did not stay formed when scooped on the plate. - Scooped food on four resident plates were left uncovered after these plates were placed inside the open food cart. 3. Dietary staff switched from one kitchen task to the next without performing handwashing. 4. Dietary staff's hair was not fully secured with the hairnet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted respect and dignity for four of 15 sampled residents (Resident 18, Resident 22, Resident 8, and Resident 12) when: 1. For Resident 18, Certified Nursing Assistant 1 (CNA 1) remained standing while feeding the resident her meal. 2. For Resident 22, CNA 2 remained standing while feeding the resident her meal. 3. For Resident 8, Licensed Vocational Nurse 1 (LVN 1) did not provide privacy during eye drop administration. 4. For Resident 12, LVN 1 did not provide privacy during medication administration via Gastrostomy tube (GT, a medical device used to provide nutrition and medication to the stomach for people who are unable to swallow thru the mouth). These deficient practices had the potential to result in diminished individual dignity and a loss of self-esteem.

Inspectors wroteBased on observation, interview, and record review, for one of 15 sampled residents (Resident 26) with limited range of motion (ROM, a joint or body part with limited range of motion cannot move through its normal range of motion, also known as contractures), the facility failed to apply the ankle foot orthosis [AFO, boot(s) or external supportive devices used on lower legs/feet to stabilize the joints to prevent contractures] to Resident 26's left foot as ordered by the physician. This failure resulted in Resident 26's unmet care needs and had the potential to result in worsening of left foot contracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the prevention of complications of enteral feedings for one of one sample selected resident who has a feeding tube at the facility (Resident 12) when Licensed Vocational Nurse (LVN) 1 administered the medication and water via gastrostomy tube (GT-a tube inserted through the abdomen that brings nutrition directly to the stomach) without first checking stomach residual (amount of fluid remaining in the stomach). This failure resulted in Resident 12 vomiting after receiving the medication and water via GT, and a potential for Resident 12 to aspirate (breathe in food or liquid into the airway).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prevention of infection for one of 15 sample selected residents (Resident 12), when Licensed Vocational Nurse (LVN) 1 did not disinfect the blood pressure device between resident use. This failure had the potential of transmitting infection between the residents who are residing at the facility.

Inspectors wroteBased on observation and interview the facility had five residents (Rt)'s rooms (room [ROOM NUMBER], 2, 4, 5 and 8) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for delivery of care to each of the residents in each room, or for storage of the residents' belongings.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that enhanced the dignity of two (Residents 5 and 16) of 11 sampled residents when two staff members (Certified Nursing Assistant 1 and Certified Nursing Assistant 5) stood and leaned over the residents during feeding assistance with two meals. This failure had the potential for Residents 5 and 16 to feel embarrassed and disrespected.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, safe, home-like environment for: 1. One of 11 sampled residents (Resident 17), when Resident 17's bed moved whenever Resident 17 stood up or sat down on the bed. Resident 17's room had a light fixture with a non-functioning bulb, the floor on one side of his bed was not cleaned, and there was a pile of empty garbage bags on the floor near the head of his bed. 2. Residents who used the shower room, when the shower room floor had an unlabeled hairbrush, with hair in the bristles, and a shelf in the shower room had the following items: a face mask, used gloves, four empty bottles of lotion, one bottle of conditioner, and an empty box of disposable razors. These failures resulted in: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure one of (Resident 179) of 11 sampled residents received four medications as ordered by the physician. 2. Ensure expired medications were not available for resident use when one expired intravenous antibiotic (ertapenem) and one expired influenza vaccine were stored in the medication room refrigerator. These failures had the potential for: 1. Resident 179 to not receive medications as needed for therapeutic effect, or adverse effects if medications were administered too closely together. 2. A residents to receive expired, less effective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and implement infection control measures for six of 11 residents (3, 5, 10, 19, 21, and 23) when: 1. Certified Nursing Assistant 1 (CNA 1) did not perform hand hygiene (wash hands with soap and water or use an alcohol-based hand rub) between consecutive meal tray deliveries and set-up of meals for Residents 19, 21, and 5. 2. The blood pressure cuff was not sanitized between the consecutive use of Residents 10, 3, and 23. These failures had the potential to transmit infectious organisms and increase the risk of infection for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide fingernail trimming and/or facial hair removal for three of 11 sampled residents (Residents 9, 19 and 5) who were unable to perform personal grooming. These failures resulted in Residents 9, 19, and 5 appearing ungroomed, and had the potential for a reasonable person to feel a diminished sense of self-esteem; the ragged nails also had the potential to cause injury from scratches or skin tears.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist's medication regimen review (MRR) was promptly acted upon for one (Residents 5) of 11 sampled residents. This failure had the potential for delayed treatment and increased risk of adverse side effects for Residents 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident 23) of 11 sampled residents was free of significant medication errors when Licensed Vocational Nurse 2 (LVN 2) did not follow the medication instructions to shake the Dilantin suspension (a liquid preparation of medication used to prevent seizures) before administration. This failure had the potential to result in uneven distribution of medication in the liquid and prevent administration of the ordered dose necessary to maintain Resident 23's therapeutic drug level (the concentration of medication in the blood stream necessary to prevent seizures).

Inspectors wroteBased on observation, interview, and record review, the facility failed to sanitize the ice machine's ice bin at the time of installation. This failure had the potential to result in resident food borne illness from contaminated ice.

Inspectors wroteBased on observation and interview, the facility had one resident room (room [ROOM NUMBER]), that accommodated more than four residents. This failure had the potential to result in insufficient space to provide care to each of the five residents, and inadequate space to store their personal belongings.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 17 of 17 residents in the following multiple resident bedrooms (Rooms 1, 2, 4, 5, 8) with at least 80 square feet per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside. After observation and interview, there was adequate space for residents and staff to move about without obstruction. Recommend granting waiver.