St. Anthony's Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices (ensuring staff utilized hair restraints, specifically beard guards while in the kitchen)2. The facility failed to label and date all food items in the kitchen. These failures could place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 (Resident #3, Resident #30, and Resident #94) of 16 residents reviewed for resident rights. 1. The facility failed to ensure Resident #3, and Resident #30 were fully informed and aware of their rooms being searched and why items were taken from their rooms. 2. The facility failed to assess Resident #3 and Resident #30 in their abilities to safely use razors and/or scissors, according to the facility policy, before removing them from their possessions.3. The facility failed to honor Resident #94's rights when he was being fed in the dining room by CNA C, who was standing while feeding the resident, violating his right to dignity. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 8 residents (Resident #3) reviewed for care plans. The facility failed to care plan Resident #3's use and possession of an electric razor, that was stored in his room. This failure could place residents at risk of not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1of 8 residents (Resident #94) reviewed for infection control. The facility failed to ensure CNA C did not blow on on each bite of food to cool it off before feeding it to Resident #94. This deficient practice could place residents at risk by exposing them viral infections, secondary infections, communicable diseases.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had a right to personal privacy and confidentiality of his or her personal and medical records for 3 of 10 residents (Resident #47, Resident #352, and Resident # 354) residents reviewed for personal privacy. CNA A, CNA B, and CNA C failed to knock before entering Resident #47, Resident #352, and Resident # 354's rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home.

Inspectors wroteBased on interview and record review, the facility failed to ensure competent nursing services for 1 (Resident #21) of 10 residents reviewed for competent nursing services. 1. The facility failed to accurately administer and log a medication and then identify and report a medication administration error. This deficient practice puts the residents at risk for decline in physical condition that is unacknowledged by the facility, a risk for potential for adverse reactions due to improper medication administration and a decrease in quality of life for the residents. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 4 of 11 residents (Resident #74, Resident #26, Resident #91, and Resident #64) reviewed for infection control. 1. LVN C provided catheter care and peri-care to Resident #74 without conducting hand hygiene with glove changes. 2. LVN F provided suprapubic catheter care to Resident #26 with without conducting hand hygiene with glove changes. 3. LVN D provided wound care to Resident #91 without conducting hand hygiene with glove changes. 4. CNA D provided peri-care to Resident #64 without conducting hand hygiene with glove changes. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a baseline care within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 10 residents (Resident #21) reviewed for baseline care plans. The facility failed to create a baseline care plan was created for Resident #21 within 48 hours of admission that addressed the resident's need for nutrition via enteral feeds. This failure could place the resident at risk of further malnutrition, a lack of continuity of care and communication among nursing home staff, reduced resident satisfaction of care, and reduced safeguards against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from any significant medication errors for 1(Resident #21) of 10 residents reviewed for medication errors. 1. The facility failed to accurately administer and log a medication and then identify and report a medication administration error. This deficient practice puts the residents at risk for decline in physical condition that is unacknowledged by the facility, a risk for potential for adverse reactions due to improper medication administration and a decrease in quality of life for the residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurate for 1 (Resident #28) of 10 residents reviewed for medical records. The facility failed to ensure nursing staff monitored and documented oxygen saturation levels with ordered weekly vital signs for Resident #28. This deficient practice puts the residents at risk for decline in physical condition that is unacknowledged by the facility, a risk for potential for adverse reactions due to improper medication administration and a decrease in quality of life for the residents. [...]

Inspectors wroteBased on interviews and record review the facility failed to provide care, consistent with standards of practice, to prevent pressure injuries for one resident (Resident #1) of six reviewed for pressure injuries. The facility failed to have a system in place to monitor Resident #1 for skin changes and prevent the development of right lateral foot and ankle blanchable redness from admission on [DATE] through discharge on [DATE]. On 10/13/2024, when family attempted to examine Resident #1's foot, he made a sound and pulled his foot away from their touch. This failure could place residents at risk for the development of pressure injuries, wounds infection, and pain.

Inspectors wroteBased on interviews and record review the facility failed to provide pharmaceutical services to include the acquiring and administering of medications to meet the needs of each resident for 1 of 6 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1 received his prescribed medication for Parkinson's disease (disorder of the central nervous system that affects movement) from 10/11/2024 to 10/13/2024. Resident #1 missed 5 doses of this medication causing him discomfort and increase in symptoms. This failure placed residents at risk for pain, increases in symptoms, medical complications, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of five residents reviewed for quality of care. The facility failed to carry out physician orders for a urinalysis for Resident #1 to diagnose a possible urinary tract infection. This failure could place residents with possible urinary tract infections at risk of sepsis, renal failure, and pain.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident was treated with dignity for 1 of 8 (Resident #53) residents who were observed for resident rights. The facility failed to place Resident # 53's transparent plastic catheter bag containing urine, which was visibly hanging off the resident's bed, in a non -translucent dignity bag to obscure its view from others. This placed the resident at risk for indignity, diminished quality of life, and loss of self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise the care plan for 1 of 8 (Resident # 40) residents reviewed for care plans. Resident # 40's care plans inaccurately reflected indwelling catheter use. This failure placed the resident at risk of not having their needs met to achieve the highest quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 8 residents (Residents # 15 and Resident # 53) reviewed for pressure ulcers. The facility failed to perform repositioning Q (every) two hours for resident # 15 and Resident # 53 on 11-9-2023 to prevent skin breakdown and pressure ulcers. This failure placed residents at risk of developing pressure ulcers/wounds, worsening pressure ulcers/wounds, pain, infection, or hospitalization.