St. Anthony Senior Services

Inspectors wroteBased on observations, clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to protect the resident's right to be free from physical abuse by a facility staff member for 1 of 3 residents (Resident #1). The facility reported a census of 73 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASRR) evaluation for 1 of 2 residents reviewed (Resident #12). The facility reported a census of 75 residents.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to accurately transcribe written physician orders for psychotropic medications with correct medication end dates into the electronic medical record for 2 of 3 residents reviewed (Resident #5 and #62). The facility reported a census of 75 residents.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to follow proper infection control practices during catheter care to prevent urinary tract infections and skin infection for 1 of 2 residents observed (Resident #5). The facility reported a census of 75 residents.

Inspectors wroteBased on clinical record reviews, hospital record review, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 3 residents reviewed (Resident #1) for falls. The facility failed to implement effective interventions and follow the care plan to prevent falls. Resident #1 was at risk for falls and had a history of repeated falls with trends. Resident #1 had eight falls from January 2025 to August 2025. On 6/1/25 Resident #1 had a fall in her room after attempting to self transfer from her wheelchair to her recliner, resulting in her hitting her head and sustaining a laceration to her forehead requiring an emergency room (ER) visit and 8 staples. On 8/8/25 she fell again in her room after attempting to self transfer from wheelchair to her recliner, resulting in her hitting her head and left hip pain. [...]

Inspectors wroteBased on observation, staff interviews and policy review, the facility failed to ensure open items were dated, covered and labeled. The facility further failed to ensure staff used proper hand hygiene practices during lunch service while serving food. The facility reported a census of 76 residents.

Inspectors wroteBased on resident record review, staff interviews, observation and facility policy review the facility failed to verify the resident's advanced directive choice documented accurately for 1 (Resident #58) of 24 residents reviewed. The facility reported a census of 76 residents.

Inspectors wroteBased on resident record review, staff interview, and facility policy review the facility failed to develop and implement a comprehensive person-centered care plan to include a resident's diagnoses and treatment for urinary tract infection two times since admission and history of within 30 days of admission for 1 resident (Resident #16) of 18 residents reviewed for care plans. The facility reported a census of 76 residents.

Inspectors wroteBased on observation, interview and clinical record review, the facility failed to ensure an accurate accounting of Scheduled 2 (II) (high potential for abuse) controlled medications for 1 of 3 residents reviewed. On 1/3/25, staff reported that Resident #44 was missing a dose of Ativan. The facility reported a census of 76 residents.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and facility policy review, the facility failed to protect residents from possible accidents and injuries. An electric space heater was used to provide supplemental heat to 3 rooms without out monitoring or supervision. Two rooms were in the Memory Care Unit with residents who had Brief Interview for Mental Status (BIMS) scores of 3 and 5 out of 15, indicating severe cognitive impairment. One resident was ambulatory and at risk for unsafe wandering per their Care Plan. Space heaters were provided on the weekend of 1/13/24 and removed 1/22/24 for 4 of 74 residents reviewed (Resident #1, #20, #30, and #173). The facility staff also failed to attach a lift sling to a mechanical lift correctly when transferring a resident, resulting in a fall with injury to 1 of 3 residents reviewed (Resident #29). [...]

Inspectors wroteBased on clinical record review, observations, and staff interviews, the facility failed to provide dignity by leaving a catheter bag uncovered and easily visible in the dayroom and in the bedroom to 1 of 1 resident reviewed with catheters (Resident #32). The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #32 had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, indicating severe cognitive impairment. The MDS documented a diagnosis of fluid overload, urinary retention, overactive bladder, and urinary incontinence. Observation on 1/23/24 at 10:19 AM, revealed Resident #32 sitting in a recliner in the dayroom with a catheter bag hanging on the right side of the recliner without a privacy bag in place. [...]

Inspectors wroteBased on clinical record review, family and staff interviews, and facility policy review, the facility failed to provide family with requested medical records in a timely manner for 1 of 1 resident reviewed (Resident #123). The facility reported a census of 74 residents. Findings Include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #123 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 (severe cognitive deficit.) The resident had daily behavioral symptoms such as hitting, pacing and rummaging. Resident #123 required partial assistance with eating, was dependent with toileting, required substantial assistance to transfer from sit to stand. His diagnosis included renal insufficiency, diabetes mellitus, Alzheimer's Disease, Dementia and anxiety disorder. [...]

Inspectors wroteBased on clinical record review, observation, staff interviews and facility policy review, the facility failed to follow Physicians Orders for special dietary needs for 1 of 3 residents reviewed (Resident #62). Resident #62 served a regular texture meal when the order was for pureed texture. The facility reported a census of 74 residents Findings Include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #62 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 (severe cognitive deficit). The resident identified severely impaired, never/rarely made decisions and was totally dependent on staff for help with meals. The Care Plan dated 2/9/23, showed that Resident #62 at risk for fluid imbalance related to being dependent on staff to provide and prompt her to consume adequate fluids. [...]

Inspectors wroteBased on clinical record review, observations, resident and staff interviews the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 2 residents reviewed, requiring the use of oxygen (Resident #17). The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #17 had a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating no cognitive impairment. The MDS documented a diagnosis of chronic obstructive pulmonary disease. On 1/23/24 at 9:02 AM Resident #17 stated she did not remember oxygen tubing changed by staff at the facility. An Observation on 1/23/24 at 9:02 AM of Resident #17's oxygen tubing revealed a date of 12/15 on the tubing. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, the facility failed to ensure that all staff were adequately trained on the use of mechanical lifts for 1 of 3 residents reviewed who required a mechanical lift to be transferred (Resident #29). Resident #29 fell from the EZ Stand Lift (a Sit to Stand mechanical lift) when an Agency Staff person failed to ensure that the loop on the sling was secured with the hook. The facility did not have an orientation process in place to ensure skill competency on the use of mechanical lifts. The facility reported a census of 74 residents. Findings Include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #29 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, (moderate cognitive deficit). [...]

Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to review the use of as needed (PRN) psychotropic medications for Resident #54's PRN topical Ativan ordered 6/19/23. The facility also failed to ensure psychotropic medications are only used when the medication is necessary and PRN use is limited for Resident #123 who had a diagnosis of dementia with agitation and confusion. Resident #123 had several different as needed (PRN) psychotropic medication orders to help with the anxiety. Staff overlapped the administration of these PRN medications and the resident was found to be lethargic the next day. The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #54 as rarely/never understood for documentation of Brief Interview for Mental Status (BIMS). [...]

Inspectors wroteBased on clinical record review, document review, and staff interviews, the facility failed to keep accurate drug records for all controlled medications (Hydrocodone-APAP 5/325 milligram (mg)) for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #4 with a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating no cognitive impairment. The MDS documented a diagnosis of multiple sclerosis, muscle spasm, and migraine. Review of Resident #4's Physician Orders revealed an order for Hydrocodone-Acetaminophen tab 5-325 mg give one tablet by mouth two times a day for pain hold if lethargic. [...]

Inspectors wroteBased on observation, clinical record review, staff interview, and facility policy review, the facility failed to provide appropriate infection prevention practices by not utilizing proper hand washing during administration of medications to 1 of 7 residents reviewed (Resident #59). The facility reported a census of 74 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #59 rarely/never understood for documentation of Brief Interview for Mental Status (BIMS) . The MDS documented a diagnosis of fracture of an unspecified part of neck of unspecified femur closed fracture with routine healing. An observation on 1/24/24 at 8:07 AM, revealed Staff A, Registered Nurse (RN) removed medication cassettes from the medication carts for Resident #59. Staff removed medications from medication cassettes into a medication cup. [...]

Inspectors wroteBased on observations, clinical record review, staff interviews, and facility policy the facility failed to provide adequate supervision to ensure residents remained safe from another resident for 3 of 5 residents reviewed (Residents #3, #4 and #5). In addition, the facility failed to provide 1 of 5 residents reviewed with enough supervision to prevent him for attempting to hurt other residents (Resident #6). Resident #6 had physical altercations on 11/18/23 with Resident #4, 11/21/23 with Resident #5, and 11/24/23 with Resident #3.