St. Anthony Park Home Inc

Inspectors wroteBased on interview and document review the facility failed to ensure 1 of 8 staff nursing assistant (NA)-M had completed the required Alzheimer's and dementia care training program. This had the potential to affect all residents in the facility who had an Alzheimer's or dementia diagnosis.

Inspectors wroteBased on observation, interview, and document review, the facility failed to honor a request for different room lighting for 1 of 1 resident (R5), reviewed for self-determination.

Inspectors wroteBased on interview and record review, the facility failed to ensure a PRN (as-needed) antipsychotic medication was limited to 14 days and that the continued use of the PRN antipsychotic medication was evaluated by the attending physician or prescribing practitioner for 1 of 1 residents (R12) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure written transfer notices were provided as soon as practicable for 1 of 1 resident (R79) reviewed for hospitalization.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 1 of 1 residents (R77) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene care (i.e., nail care, shaving) was provided for 2 of 2 residents (R58, R5) reviewed for activities of daily living (ADLs) and were dependent on staff for their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sleeve protector was provided in accordance with the comprehensive care plan for 1 of 1 residents (R12) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide the ordered services for the behavioral health needs for 1 of 1 resident (R22) reviewed for mood and behavior. Findings Include:R22's quarterly Minimum Data Set (MDS) dated [DATE], indicated R22 was cognitively intact, and had no hallucinations or delusions. The MDS indicated R22 was depressed, had trouble falling asleep, had poor appetite, and had diagnoses of heart failure, Parkinson's disease, anxiety and depression disorder. R22's Medical orders dated 7/13/26, indicated an order for escitalopram oxalate 10 milligrams daily for depression. This order was dated 7/30/24. R22's care plan dated 7/13/26, indicated resident had potential for alteration in mood related to depression, and anxiety. The interventions directed staff to arrange for a psychology and follow-up consult as indicated. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring was in place for 1 of 1 resident (R9) on a high-risk medication (i.e., a diuretic), reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 1 resident (R10) reviewed for catheter and 1 of 1 resident (R2) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn by staff according to the Center for Disease Control and Prevention (CDC) guidelines for a facility in outbreak status. This had the potential to affect all 73 residents in the building.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a low-temperature sanitization commercial dishwasher used in 1 of 1 main production kitchen was adequately monitored (i.e., every shift) to ensure effective chemical concentration and dishware sanitization to reduce the risk of foodborne illness. This had potential to affect all 72 residents, staff and visitors who consumed food from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to report a suspected Norovirus outbreak to the State Agency (SA) as required. This had the potential to affect all 72 residents residing in the facility. In addition, the facility failed to ensure a blood glucose machine was kept in good repair to ensure the surface could be adequately disinfected and for 1 of 4 residents (R40) reviewed for medication administration. The facility also failed to ensure proper hand hygiene and glove use was utilized for 1 of 2 residents (R62) observed during personal cares.

Inspectors wroteBased on interview and document review, the facility failed to implement an antibiotic stewardship program which included development of protocols and a system to monitor appropriateness of antibiotic including prophylactic antibiotic use to prevent antibiotic resistance and help prevent the spread of infectious diseases. This had the potential to affect all 72 residents residing in the facility. In addition, the facility failed to ensure an ongoing review of prophylactic antibiotic use for 1 of 1 residents (R51) reviewed for oral antibiotic use. R51 R51's admission Minimum Data Set (MDS) dated [DATE], indicated R51 had intact cognition and had been admitted to the facility on [DATE]. R51's provider note dated 5/20/25, indicated R51 was diagnosed with anemia and wounds of the left and right ankle. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a dignified dining experience by serving meals on hard plastic trays which had the potential to affect all residents who ate in the dining room. Additionally, the facility failed to ensure all staff knocked on individual resident bedroom doors and introduced themselves prior to entry for 1 of 1 residents (R62) reviewed with concerns with staff entering their room.

Inspectors wroteBased on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits, for 4 of 4 residents (R56, R10, R40, R47) reviewed for use of psychotropic medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a medication was administered safely for 1 of 1 resident (R10) who had been assessed as unable to safely self-administer medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure symptoms of potential psychiatric distress were recorded; and non-pharmacological interventions were attempted then documented prior to the use of as-needed (i.e., PRN) psychotropic medication to improve continuity of care for 1 of 5 residents (R56) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a comprehensive care plan for hospice care and services was developed and/or readily available to promote continuity of care for 1 of 1 resident (R56) reviewed for hospice services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to coordinate care with an outside hospice agency to ensure ongoing, consistent care delivery and promote comfort for 1 of 1 resident (R56) reviewed for hospice services. In addition, the facility failed to assess and appropriately monitor developing bruising to ensure healing for 1 of 1 resident (R46) reviewed who had visible bruising on their skin.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively reassess to help determine what, if any, additional interventions were required to promote healing and reduce the risk of complication after an in-house acquired pressure injury developed for 1 of 2 residents (R56) reviewed for pressure ulcer care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess for, and implement as appropriate, a nursing functional maintenance program to ensure 1 of 3 residents (R15) maintained and/or improved their highest level of range of motion (ROM).

Inspectors wroteBased on observation, interview, and document review, the facility failed to complete ongoing pain assessments and timely intervention when signs of pain were observed for 1 of 4 residents (R15) reviewed for pain, with severely impaired cognition.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and attempt alternatives for 1 of 1 resident (R46) reviewed who had grab bars affixed to their bed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure physician-ordered medications were re-ordered timely to prevent delay in administration and reduce the risk of complication for 1 of 4 residents (R40) observed to receive medication during the survey.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident choice with meal preferences was attempted and/or honored to promote quality of life for 1 of 1 resident (R35) reviewed who wanted to have fried eggs (i.e., runny yolk) and was told they could not have them.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the most recent recertification survey along with subsequent complaint investigation results were readily available and accessible within the care center. This had potential to affect all residents, staff, and visitors whom could wish to review the information.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident personal fund accounts were insured with adequate surety bond coverage (a contract or promise by a surety or guarantor to pay a certain amount if a second party fails to meet the obligation) to cover the total account balance. This had potential to affect all residents identified to have an account with a positive balance.

Inspectors wroteBased on interview and document review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) who was at risk for elopement. This resulted in an immediate jeopardy (IJ) for R1 when he eloped from the facility and was found half a block away. The IJ began on 9/27/24 at 4:00 p.m. when therapy director (TD)-A discovered R1 outside of the facility on the sidewalk, approximately half a block from the building. The administrator and director of nursing (DON) were informed of the IJ on 10/3/24 at 4:53 p.m. The IJ was removed on 10/4/24, but noncompliance remained at the lower scope and severity level of D - isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Inspectors wroteBased on observation, interview and document review, the facility failed to take appropriate steps to ensure the proper sanitization of dishware used for meal preparation and resident service when 1 of 1 high-temperature commercial dishwashers was identified as not reaching adequate final rinse temperature (i.e., 180 F). This had potential to affect all 80 residents within the nursing home, staff, and visitors who consumed food from the main production kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident's needs were addressed in a respectful and dignified manner when a resident (R34) used a call light for help. Additionally, the facility failed to ensure all staff knock on individual resident bedroom doors and introduce themselves prior to entry for 3 residents (R68, R76, R74). Furthermore, the facility failed to provide a dignified dining experience for 3 residents (R21, R31, R68).

Inspectors wroteBased on interview and document review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) upon the termination of Medicare A coverage for 1 of 3 residents (R74) reviewed who remained in the nursing home after Medicare A coverage ended.

Inspectors wroteBased on interview and document review, the facility failed to respond to and resolve a report of missing clothing for 1 of 1 residents (R182) reviewed for grievances.

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of potential abuse were reported in a timely manner to the state agency (SA) for 1 of 1 residents (R21) whose allegations were reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure routine personal care (i.e., incontinent cares, nail care) were provided for 2 of 3 residents (R6, R31) reviewed for dependent activities of daily living (ADL's).

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure assessed and care-planned interventions for preventative skin care were consistently implemented for 1 of 1 residents (R31) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure behaviors of potential wandering were comprehensively assessed and, if needed, interventions placed to ensure safety and prevent elopement for 1 of 1 residents (R330); and failed to ensure fall interventions were implemented to prevent fall and injury for 1 of 3 residents (R64) reviewed for falls and accidents.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess past trauma and develop a comprehensive person-centered care plan with goals and interventions utilizing a trauma-informed approach including monitoring of PTSD (post-traumatic stress disorder) for 1 of 1 (R76) residents reviewed for trauma-informed care.

Inspectors wroteBased on interview and document review, the facility failed to act upon the consultant pharmacist's recommendation for 1 of 1 resident (R13) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to administration of as-needed (PRN) narcotic medication to reduce the risk of potential complications for 1 of 5 residents (R4) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure an appropriate indication was given for continued antipsychotic medication use for 1 of 5 residents (R68) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure the need for routine dental care (i.e., dental appointment) was assessed and, if needed or wanted, offered to promote oral hygiene and reduce the risk of complication for 1 of 1 resident (R4) reviewed who reported losing their dentures just prior to admission.

Inspectors wroteBased on interview and document review, the facility failed to ensure recommended pneumococcal immunizations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 1 of 5 residents (R18) reviewed for immunizations. This had the ability to affect all 80 residents residing the in the facility