St. Antoine Residence

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that the attending practitioner was immediately notified of a significant change in a resident's physical and clinical status for 1 of 1 resident reviewed with a change in condition, Resident ID #1. Specifically, nursing staff failed to notify the provider of Resident #1's acute decline in functional mobility (digressing from a 2-assist walker transfer to requiring the use of a mechanical lift for transfers) and multiple clinical manifestations of unmanaged pain (wincing, grimacing, heavy lateral leaning, and pointing to his/her right lower extremity) following consecutive falls on 6/16/2026 and 6/17/2026.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to maintain medical records for each resident that are complete and accurately documented, in accordance with accepted professional standards of practice for 1 of 1 resident reviewed for transfer status, Resident ID #3.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to establish an Infection Prevention and Control Program (IPCP) that includes, at a minimum, an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use to ensure that residents who require an antibiotic, are prescribed the appropriate antibiotic for 5 of 6 residents reviewed for antibiotic use, Resident ID #s 5, 13, 16, 89, and 165.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that a resident received adequate assistive devices and failed to communicate changes in recommended assistive devices to caregivers to prevent accidents, for 1 of 2 residents reviewed who utilized a stand aid (a device used to assist individuals in transitioning from a sitting to a standing position and transferring from surface to surface) for transfers, Resident ID #165.

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 residents reviewed for oxygen use, Resident ID #76.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice for 1 of 1 resident reviewed with a pre-cancerous lesion to the right temple, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to follow standard precautions to prevent the spread of infection and to ensure a sanitary environment to help prevent the transmission of infections for 1 of 1 resident reviewed with a surgical wound, and an indwelling medical device, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to keep a resident free from abuse for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to develop and maintain policies and procedures for the facility to act on pharmacy identified irregularities marked as Clinical Priority) for 1 of 1 resident reviewed for the use of Clozapine (Clozaril, an atypical antipsychotic medication prescribed for treatment-resistant schizophrenia, recurrent suicidal behavior in schizophrenia), Resident ID #1.

Inspectors wroteBased on record review and staff interview it has been determined that the facility failed to keep all residents free from significant medication errors for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety relative to the main kitchen.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that residents with pressure ulcers receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents reviewed for pressure ulcers, Resident ID #s 38 and 153.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to 3 of 3 residents reviewed for wound care, Resident ID #s 77,153, and 162. Additionally, the facility failed to maintain Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] in nursing homes) for 2 of 4 residents reviewed with pressure injuries, Resident ID #s 77 and 146.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that a Nurse Practioner provide orders for the resident's immediate care and needs for 1 of 1 resident reviewed for physician orders with acute urinary retention (inability to empty the bladder) Resident ID #153.

Inspectors wroteBased on record review, resident and staff interviews, it has been determined that the facility failed to ensure that each resident receives adequate supervision to prevent accidents, for 1 of 3 residents reviewed for falls resulting in transfer to a hospital, Resident ID #62.

Inspectors wroteBased on record review, resident and staff interviews, it has been determined that the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety for 1 of 3 residents reviewed for falls resulting in a hospital transfer, Resident ID #62.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored and distributed, in accordance with professional standards for food safety relative to the main kitchen and 2 of 3 kitchenettes.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to assist residents in obtaining routine dental care for 4 of 7 residents reviewed for dental services, Resident ID #s 12, 31, 44, 91, and 94.

Inspectors wroteBased on surveyor observations, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections relative to COVID-19 and enhanced barrier precautions (EBP) for 2 of 4 nursing units, affecting Resident ID #s 8, 11, 52, 59, 84, and 117.

Inspectors wroteBased on surveyor observation, record review, resident and staff interviews, it has been determined that the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 3 of 3 shower trolleys reviewed.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that all alleged violations are thoroughly investigated for 1 of 1 resident reviewed who was noted to have bruising to his/her nipple, Resident ID #87.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to provide care consistent with the comprehensive care plan for 1 of 1 resident reviewed who required colostomy care, Resident ID #230. Record review revealed the resident was admitted to the facility on [DATE] with a diagnosis including, but not limited to, colostomy status (a surgical procedure in which a piece of the large intestine is diverted to an artificial opening in the abdominal wall). Record review of a hospital document with discharge instructions dated 12/27/2023, states in part, .If your colostomy output is less than 500 ml [milliliters]/day .please call your surgeon . Record review revealed an order dated 1/3/2024 to monitor colostomy output every shift if less than 500 ml daily, contact the surgeon. [...]

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 7 residents reviewed for nutrition, Resident ID #218.