St. Anthony Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers for three residents (R104, R106 and R110) out of three residents with pressure ulcers reviewed, resulting in the development of facility acquired stage 4 (full thickness tissue loss with exposed muscle, tendon and or bone) pressure ulcers. Findings Include: This citation includes intake number 3005546. [...]

Inspectors wroteThis citation pertains to intake 2609532Based on interview and record review, the facility failed to ensure timely identification and treatment of pressure ulcers for one (R701) of four residents reviewed for pressure ulcer care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to eliminate harborage conditions to maintain an effective pest control program. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistantly implement an effective measure (seperation) to prevent further abuse during an abuse investigation for one resident (R324) out of two residents reviewed for abuse.

Inspectors wroteThis citation relates to Intake #MI00148781. Based on observation, interview, and record review, the facility failed to provide food which accommodated residents' allergies for two Residents (R703, R706) of seven residents reviewed for food allergies.

Inspectors wroteThis citation pertains to Intake M100147381. Based on observation, interview, and record review, the facility failed to ensure one of one kitchen hand washing station was supplied with soap and paper towel.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the main floor kitchenette, and in the rehab and second floor pantry. This deficient practice had the potential to affect all residents in the facility that consume food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure paper towel dispensers were accessible for one (R9) resident and two anonymous group residents of five residents reviewed for accommodations.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care planned interventions were implemented for two residents (R74, R102) of three reviewed for care and repositioning needs resulting in and the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an incontinence pad and gown were changed during incontinence care and clothing was available for one resident (R119) of one reviewed for care.

Inspectors wroteOn [DATE] at 5:34 PM, an observation of the second floor A medication cart with Licensed Practical Nurse (LPN) A revealed and open and undated, Basalgar insulin pen, and open and undated Glargine insulin pen and an open and undated Levemir insulin pen. A vial of glucose test strips also not dated when opened and or with an expiration date. On [DATE] at 6:05 PM, an observation of the Rehab medication cart A with Registered Nurse (RN) B revealed a Latanoprost .005% eye dropper vial were open and undated and without a resident identifier on the vial. On [DATE] at 9:08 AM, an observation of the one north A medication cart with LPN D revealed, a Humalog insulin vial was not labeled with a resident identifier, a Breo inhaler was not labeled with a resident identifier on the inhaler, and a Trellegy inhaler was not labeled with the date opened or the expiration date on the inhaler. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident (R125) was offered a bedtime snack of eight residents reviewed for snacks, resulting in nighttime hunger.

Inspectors wroteThis Citation pertains to Intake Number M100131450. PNC was accepted for this citation. Based on observation, interview and record review, the facility failed to provide adequate supervision for one resident (R81) of six residents reviewed for elopement by allowing the resident, who was severely cognitively impaired, ambulatory and identified as an elopement risk, to exit the building unbeknownst to facility staff while wearing a Wanderguard bracelet, including use of an alarmed elevator and exiting an alarmed door between approximately 9:15 PM - 9:25 PM on 08/07/2022. This deficient practice resulted in the likelihood of serious injury or death from being unsupervised outside in the dark near a busy four-lane road in the parking lot of a business adjacent to the facility. [...]

Inspectors wroteThis citation pertains to Intake Number MI00132074. Based on observation, interview and record review, the facility failed to complete/document accurate skin/wound assessments, and implement wound care interventions for three sampled residents (R64, R80, and R285) of six residents reviewed for skin care, resulting in unmet care needs and the potential for the worsening of wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to care plan interventions for two residents (R114 and R286) of four residents reviewed for care planning, resulting in interventions not being implemented and monitored regularly. Findings Include: R114 On 2/27/2023 at 10:53 AM, R114 was observed in the bed. R114 was observed to have two large green body pillows on each side of them. R114 was unable to be interviewed. A review of the medical record revealed that R114 initially admitted into the facility on [DATE] with the following diagnoses, Muscle Wasting, Muscle Weakness, and Difficulty in Walking. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0/15 indicating a severely impaired cognition. R114 also required extensive two person assist with bed mobility and transfers. [...]

Inspectors wroteThis Citation pertains to Intake Numbers MI00129936 and MI00132074. Based on observation, interview, and record review the facility failed to ensure that toileting and/or emptying of a colostomy bag was addressed in a timely manner for two residents (R99 and R117) of three residents reviewed for Activities of Daily Living (ADL) care, resulting in feelings of frustration, aggravation, and dissatisfaction with care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete and/or document catheter care according to physician's orders and the care plan for one resident (R80) of one resident reviewed for catheter care, resulting in the potential for recurrent urinary tract infections and discomfort. Findings Include: R80 On 2/26/2023 at 10:49 AM, R80 was observed laying in bed. R80 was observed to have an indwelling Foley catheter that was draining dark amber urine. A review of the medical record revealed that R80 was admitted into the facility on 2/27/2019 with the following diagnoses, Parkinson's Disease and Dysphagia. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12/15 indicating moderately impaired cognition. R80 also required extensive two-person request. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to serve food in a palatable manner and/or at the preferred temperature for five residents (R20, R126, R9, R38 and R78) of eight residents and two anonymous residents ([NAME] and RZ) reviewed for food palatability, resulting in resident dissatisfaction during meals.