St. Anthony's Nsg & Rehab Ctr

Inspectors wroteBased on interview and record review, the facility failed to administer intravenous medications as ordered by the physician, for one of one resident (R1), reviewed for medications, in the sample of three. R1's Hospital After Visit Summary documents that R1 was hospitalized from [DATE] to 6/22/26 with a diagnosis of cellulitis of toe of right foot. This same form includes the following physician orders Daptomycin (antibiotic) 50 MG (Milligrams)/ML (Milliliter). Inject 540 MG into the vein daily for 21 days. R1's facility Medication Administration Record, dated June 2026 documents that the administration times of R1's Daptomycin was changed on 6/27/26, by facility staff, from daily at 8:00 A.M., to daily at 4:00 P.M. [...]

Inspectors wroteBased on record review and interview the facility failed to prevent a resident to resident altercation between two of 6 residents (R1, R2) reviewed for abuse allegations. On 7/17/26 at 11:30am R2 stated, I remember that guy that hit me. He pulled me by my (gestured towards oxygen tubing) towards him, I thought he was going to punch me but he just kind of slapped me in the forehead and I got the hell away from him. I am not scared. (V1/Administrator) called the cops, he took care of it. This resident-to-resident altercation is documented in R1 and R2's medical records, as well as facility records, including Incident/Accident logs for June 2026. The altercation was reported to the state agency on 6/22/26, and documents on 6/22/26 at 2:15pm, R1 and R2 were in the facility's elevator when R1 pulled R2's oxygen cannula off R2's face and hit R2 on the forehead with an open hand on 6/22/26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were within reach and working for residents. This applies to 4 of 8 residents (R1, R2, R4, & R8) reviewed for call lights in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was transferred in a safe manner. This applies to 1 of 3 residents (R2) reviewed for safety in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to ensure a wound culture was picked up in a timely manner. This applies to 1 of 3 residents (R1) reviewed for lab services in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure there was reasonable access to phone communication for residents (R1 & R3) reviewed for residents' rights in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident at moderate risk for skin impairment received interventions to prevent and properly manage an unstageable pressure ulcer, resulting in deterioration of the wound and osteomyelitis for one (R2) of three residents reviewed for pressure ulcers. This failure resulted in R2's wound progressing to a painful facility acquired an unstageable pressure ulcer with tunneling and osteomyelitis, requiring intravenous antibiotics and debridement.

Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing department was directed by a qualified Director of Nursing responsible for oversight of nursing services and coordination of care, resulting in a lack of direction and communication within the nursing department and therapy regarding resident care needs for one (R1) of three residents reviewed for gastrostomy tube (G-tube) management. This failure has the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the nursing department was directed by a qualified Director of Nursing responsible for oversight of nursing services and coordination of care, resulting in a lack of direction and communication within the nursing department and therapy regarding resident care needs for one (R1) of three residents reviewed for gastrostomy tube (G-tube) management. This failure has the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain resident room temperatures at a comfortable, safe level for three of seven residents (R1, R5 and R7) reviewed for comfortable room temperatures, in a sample of seven. The facility policy, Emergency Procedures for Heat Loss, dated September 2017 directs staff, The inability to heat the facility can be a critical issue in many parts of the country. The loss of the heating system should be assessed quickly to determine if the situation can be remediated while temperatures remain steady in the facility. If not, partial or full building evacuation may be necessary. On 01/26/2026 at 8:20 A.M., R1 was seated in a wheelchair in his room, on the facility second floor, wearing multiple layers of clothing and a knitted hat. [...]

Inspectors wroteBased on interview and record review the facility failed to administer medication as ordered by the physician for one resident (R3), reviewed for respiratory treatments, in a sample of three residents. The facility's Medication Administration Policy dated 10/14/24 documents, The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident. R3's medical record documents R3 was admitted to the facility 9/15/25 with the following diagnoses: Acute respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease (with acute exacerbation), chronic systolic (congestive) heart failure, atrial fibrillation, and hypertension. R3's hospital discharge order documents the following: [...]

Inspectors wroteBased on interview and record review the facility failed to identify a pressure injury prior to advanced staging and failed to assess a new pressure injury for 1of 3 residents (R1) reviewed for pressure injuries in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to initiate a skin assessment upon admission, failed to initiate admission wound orders and failed to initiate an appropriate wound care plan for one resident (R1) with a sacral pressure wound of three residents reviewed for pressure wounds. This failure resulted in R1 acquiring a Stage IV necrotic sacral pressure ulcer.

Inspectors wroteBased on record review and interview the facility failed to document staff were provided education regarding the benefits and potential risks associated with the Covid-19 vaccination. This failure has the potential to affect all 82 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent one of five residents (R46) from sustaining a smoking/vape-related burn and failed to complete quarterly Smoking Assessment Evaluations for four of 18 Residents (R33, R46, R51 and R79) reviewed for smoking in the sample of 33.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident was free from sexual abuse by a staff member for 1 of 3 residents (R33) reviewed for abuse in a sample of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication and failed to provide supporting behaviors for the use of an antipsychotic medication for one resident (R21) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent a significant medication error for one resident (R21) who receives an antipsychotic medication of five residents reviewed for unnecessary medications in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff follow infection control practices during wound care, in that, V4/Licensed Practical Nurse failed to change gloves during pressure ulcer wound care for R25. This failure has the potential to effect one resident [R25] of two residents reviewed for Pressure ulcer wound care, in a total sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the survey binder readily available, and in a conspicuous place, for residents review the results of State Agency surveys. This failure has the potential to affect all 82 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to change an indwelling catheter as ordered and failed to monitor urinary output for one resident (R6) of three residents reviewed for indwelling catheter in a total sample of seven. Findings Include: R6's Physician Order Sheet dated October 2024 documents 16 fr (french) (indwelling) catheter for neurogenic bladder. Change every month and PRN (As needed). On 1/31/25 at 10:00 AM V2 (Registered Nurse/Director of Nursing) stated that all residents with catheters should have I & O (Intakes and Outputs) done every shift. V2 stated that she was not aware of any issues with R6's catheter. R6's Electronic Medical Record did not contain any documentation of R6's urinary output from the time of his admission [DATE]) until transfer to the hospital (1/23/25). [...]

Inspectors wroteBased on Interview and Record review, the facility failed to report an allegation of misappropriation of jewelry to the state agency or local law enforcement for one of three residents (R1) reviewed for misappropriation in the sample of four.

Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy and complete a background check on a contracted employee with a known criminal history. This failure has the potential to affect all 89 residents currently residing in the facility.

Inspectors wroteBased on interview and record review the Facility failed to promote an environment to provide respect and dignity for four (R2, R3, R4 and R5) of five Residents reviewed for Resident Rights in a sample of five.

Inspectors wroteBased on interview, observation and record review, the facility failed to maintain an effective pest management program. This failure has the potential to affect all 80 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents cares were implemented for four of six residents (R1, R2, R4, R6) reviewed for improper nursing care in a sample of six.

Inspectors wroteBased on record review, observation and interview, the facility failed to implement isolation precautions as ordered for suspected scabies for one of two residents (R4) reviewed for infection control practices in a sample of nine.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy of protecting a resident from further potential abuse during an abuse investigation, for one of three residents (R1) reviewed for abuse in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to accurately assess a resident at risk for elopement and failed to implement interventions for a resident at risk for elopement resulting in R1 eloping form the facility unsupervised on 4/19/24 at approximately 7:00 PM. R1 did not return to the facility until approximately 1:00 PM on 4/20/24. This applies to one of three residents (R1) reviewed for elopement in the sample of eight. The Immediate Jeopardy began on 4/10/24 when R1 did not return from a leave from the facility with a friend until the city public bus system brought R1 back to the facility between 8:00 PM and 8:30 PM. When the city public bus dropped R1 off at the facility, they reported they had noticed R1 sleeping on a park bench in the local downtown area and recognized him. [...]

Inspectors wroteBased on record review and interview, it was determined the facility failed to ensure physician orders for life sustaining treatment where accurate and complete for 5 of 5 (R6, R24, R35, R38 and R58) residents in a sample of 32 residents.

Inspectors wroteBased on Observation, Interview and Record review, the facility failed to provide Range of Motion programing to residents with limitations in Range of Motion for three of three residents (R22, R45, R58) reviewed for limited range of motion in the sample of 32.

Inspectors wroteBased on Record Review and Interview, the facility failed to complete a scheduled suprapubic urinary catheter change per the physician's order for one of three resident (R22) reviewed for catheters in the sample of 32.

Inspectors wroteBased on Record Review and Interview, the facility failed to complete Physician order weekly weights for a resident with a severe protein calorie malnutrition for one of one resident (R22) reviewed for nutrition in the sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to obtain the physician ordered daily weights prior to dialysis treatments and failed to provide ongoing communication with the dialysis center for two of two residents (R27 and R38), reviewed for dialysis, in a sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to identify Post Traumatic Stress Disorder (PTSD) triggers and identify specific interventions to address the behaviors for one of one resident (R40), reviewed for PTSD, in a sample of 32.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored at the proper temperature for three of three residents (R59, R192 and R197) reviewed for medication storage, in a sample of 32.

Inspectors wroteBased on document review and interview, it was determined the facility failed to ensure infection prevention precautions were implemented for 1 of 2 (R58) residents in a sample of 32 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure pneumococcal immunizations were offered/administered to four residents (R22, R27, R35, and R57) of five residents (R6, R22, R27, R35, and R57) reviewed for pneumococcal immunization administration/status in a total sample of 32 residents.

Inspectors wroteBased on interview and record review the facility failed to prevent misappropriation of property for 8 residents (R3, R4, R5, R8, R9, R10, R11 and R12) of 12 reviewed for misappropriation of property in a sample of 13. Findings Include: 1.) R12's Incident Report dated 10/23/2023, documents the following, An investigation is currently underway in our facility regarding some narcotics allegedly identified as missing on Saturday, October 21st, 2023, at approximately 2:20PM. The narcotic is recorded as received from the Pharmacy on 2nd shift Friday, October 20, 2023. A full investigation was initiated upon suspicion on Saturday and continues at this time. R12's Packing Slip from the pharmacy, dated 10/20/2023, documents that 120 tablets/4 cards of 30 Hydrocodone/Acetaminophen tablet 7.5-325MG (narcotic pain medicine) were delivered to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for two residents (R1 and R7) of four residents reviewed for abuse in the sample of thirteen. Findings Include: R1's Initial Incident Investigation Report, with no date, documents the following: Type of Incident: Allegation of Verbal Abuse. R1's Diagnosis and Mental Status, including, but not limited to acute kidney failure, major depressive disorder, congestive heart failure, morbid obesity, muscle weakness. R1 has a BIMS (Brief Interview for Mental Status) score of 15 which indicates R1 to be cognitively intact. Incident Summary: During cares, R1 became upset with V9/CNA (Certified Nursing Assistant) because R1 stated his light had been on for a lengthy period. R1 alleges that V9 complained of having to provide cares to him and made inappropriate comments in response to R1. [...]

Inspectors wroteThis failure resulted in two deficient practice statements. A. Based on interview and record review, the facility failed to have adequate qualified staff to conduct basic life support/cardiopulmonary resuscitation (BLS/CPR) per their job descriptions, failed to provide BLS/CPR for 1 resident (R6) of 9 residents reviewed for CPR in the sample of 22. B. Based on document review and interview, it was determined the facility failed to ensure emergency equipment was available for resident care. This failure has the potential to affect all residents with a current census of 87 residents. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on [DATE]. The Immediate Jeopardy was identified on [DATE] and the administrator was notified on [DATE]. [...]

Inspectors wroteA. Based on observation, interview and record review, the facility failed to ensure tracheostomy supplies were available for tracheostomy care and emergency treatment, failed to obtain physician orders for tracheostomy care, failed to have a tracheostomy policy and procedure, failed to ensure staff were qualified and/or competent to perform tracheostomy care and order appropriate tracheostomy supplies for 3 of 3 residents (R3, R6, R7) admitted with tracheostomies int the sample of 22. These failures resulted in an Immediate Jeopardy: The Immediate Jeopardy started on [DATE]. The administrator was notified of the Immediate Jeopardy on [DATE]. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of their plan of correction and Quality Assessment oversite.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician orders were clarified upon admission to provide cares for 2 of 7 (R3, R6) residents reviewed for orders. This failure resulted in R3 and R6 receiving care without verified admission orders from their attending physician in the sample of 18.

Inspectors wroteBased on record review and interview the facility failed to ensure staff were qualified and competent related to tracheostomy care for 1 of 1 (R3) resident with a tracheostomy.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement wound interventions, failed to notify resident representative of a new wound, failed to follow physician orders, failed to develop a plan of care to address all wounds, failed to assess a posterior knee wound dressing resulting in an avoidable traumatic wound to right contracted posterior knee for one resident (R1) reviewed for wounds in the sample of four. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/27/23, the facility remains out of compliance at a Severity Level two as additional time is needed to evaluate the implementation and effectiveness of their wound management program. and Quality Assessment oversite.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain a physician's order for a hand mitt restraint, failed to re-evaluate the need for a mitt restraint and failed to document release of a mitt restraint for one resident (R1) of one resident reviewed for restraints.

Inspectors wroteBased on observation, interview and record review the facility failed to reschedule a Urology appointment, failed to provide justification for an indwelling urinary catheter and failed to provide the physician ordered size catheter for two residents (R6, R8) of three residents reviewed for urinary catheters.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician orders, dietary and dialysis recommendations for liquid nutrition and hydration for one resident (R1) of three resident reviewed for hydration.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy of assessing a resident's skin condition using a standardized assessment, failed to implement interventions to prevent the development of pressure wounds, for a resident that was at risk for developing pressure wounds and failed to monitor a resident's skin for the development pf pressure wounds. These failures resulted in R1 developing an avoidable, infected, unstageable wound that resulted in surgical amputation of R1's, first metatarsal and the development of osteomyelitis.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a registered nurse, as required. This failure has the potential to affect all 89 residents currently in the facility.

Inspectors wroteBased on interview and record review, the facility failed to update a plan of care to include pressure wound prevention interventions for one resident (R1) of three residents reviewed for pressure wounds, in sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to obtain the required weekly weights for three of three residents (R1, R2 and R3) reviewed for feeding tubes, in a sample of 3.

Inspectors wroteBased on observation and interview the facility failed to assist 11 residents (R4-R14) out of bed and provide feeding set up and assistance out of 22 reviewed for assistance with activities of daily living. Findings Include: On 10/18/23 at 8:10 AM V6 (Licensed Practical Nurse) stated We had one call in and one no call no show today, it has been only myself and (V11/Certified Nurse Aide) here since 6:00 AM when third shift left. I have had to give medicine and call a doctor and a family member, so I have not had time to help (V11) get anyone up yet. On 10/18/23 at 8:30 AM V11 (Certified Nurse Aide) stated I am waiting on (V6/LPN) to help me get the two person assist people up. But when breakfast gets up here, we will have to stop and pass trays then wait for them to get done eating and then change everyone again and get them up, hopefully before lunch. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to perform wound care as ordered by the physician for two residents (R49 and R70) of four residents reviewed for pressure ulcers in a total sample of 18. This failure resulted in causing R49's wound to bleed and lose viable tissue during a wound care treatment. Findings Include: 1. R49's Medical Records document R49 was admitted with a tunneling sacral wound and a right outer ankle wound on 10/28/22. R49's Physician Order Sheet dated December 2022 documents: Right outer ankle (Petroleum Jelly Impregnated Gauze) 1(inch)x 8 (inches): apply to the right outer ankle topically one time a day every Monday, Wednesday, and Friday, cover with (rolled gauze). On 12/14/22 at 9:00 A.M. V5 (Wound Doctor) removed the dressing on R1's right outer ankle. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to store food in a manner that ensures food safety, in that refrigerated items were opened and undated. This failure has the potential to affect 74 residents of 75 residents, residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to determine the clinical appropriateness for one resident (R47) to self-administer medications of 18 residents reviewed for medications in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to revise the individualized care plan for two residents (R47, R57) of 18 residents reviewed for care plans in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to provide oxygen humidification and failed to monitor oxygen saturation levels for one resident (R47) of three residents reviewed for oxygen administration in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication and failed to identify specific target behaviors for one resident (R34) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 18.