St Andre Health Care Facility

2. On 06/09/25 at 12:20 p.m., observed an oxygen concentrator at the bed side of Resident #10. The tubing was still attached to the machine. Resident #10 stated that [he/she] no longer uses O2 but machine is at [his/her] bedside. Resident #10 stated that they have not used O2 for a month. On 6/10/25 at 1:10 p.m. the surveyor confirmed in an interview with the Unit Manager that Resident #10 no longer uses the O2, and she will remove the concentrator. Based on observations, record reviews, interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 2 of 3 residents reviewed for respiratory care. ( #10, #13 and #23) Findings: 1. On 6/9/25 at 9:24 a.m. during an observation of Resident #13 and Resident #23s room. The tubing on an oxygen (O2) concentrator next to Resident #23's bed was draped over the machine without being stored in a sanitary manner. The tubing on the concentrator next to Resident #23's bed was draped over the concentrator and the nasal cannula was directly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the ceiling tile and support structure, and the large floor mixer, 3 of 3 days of survey. Additionally, the reach-in refrigerator was found to have a bag of cookie dough that was undated and unlabeled. Findings: On 6/9/25 at 9:15a.m. the initial tour of the kitchen was conducted with the Food Service Director (FSD) the following was observed: -an open bag of cookie dough not labeled and not dated in the reach in refrigerator; -several stained ceiling tiles throughout the kitchen; -rust covered support struts of the ceiling; - a long cob web hanging from the ceiling containing an insect; -discolorations of ceiling tile near dish machine, upon closer examination it was determined that the area was covered with a heavy layer of dust and when touched with the tip of a broom created a heavy falling of dust and debris in the area. On 6/10/25 at 7:30 a.m., during a tour of the kitchen the following was observed: dust strings hanging from the ceiling. On 6/11/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment on 3 of 3 units. Findings: On 6/11/25 at 1:30p.m. during a tour of the facility with the Administrator, the following were observed and confirmed: Third Floor: -Doorway next to stairwell near room [ROOM NUMBER] needs corner protector replaced. -room [ROOM NUMBER]: Stained ceiling tile near window. -Room: 304Wall gouged near bathroom door. -Room: 308- Stained ceiling tile. -Room:310- Stained ceiling tile in corner. -Room: 313- Bathroom has two holes in the wall that need repair. -Room: 318- Stained ceiling tile. -Bathing Suite: Baseboard broken in two places and tile missing. Second Floor: -Common area: 2 holes in the wall behind coffee bar that need repair. -Room: 212- Stained Ceiling tile in the bathroom. -Room: 214- Bathroom door has two holes. -Room: 215- Water in sink took a long while to heat up. -Room: 222- Wall in bathroom has 5 holes that need repair. First Floor: -Sun room all the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure that garbage and refuse were disposed of in a manner to prevent pest infestation for 1 of 3 survey days. (6/11/25). Findings: On 6/11/25 at 9:50 a.m. - Observed through the window that 1 of 2 dumpsters were uncovered, for 1 of 3 days of the survey. This was confirmed with the Food Service Director at the time of the observation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of facility policy, observation, and interviews, the facility failed to ensure a resident was clinically appropriate to self administer an inhaler on 3 of 3 survey days. (R65). Findings: Review of facility policy Self-Administration of Medications reviewed 8/21 states, .Specific orders for self-administration of medication by the resident must be written by the physician .An Assessment for Self-administration of Medications will be completed and signed by a licensed nurse and resident prior to initiation of self-administration . Medication Nurse shall record each shift, name of medication, number of times self-medicated on medication administration record. R65 was originally admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), and a cognitive communication deficit. Review of R65's signed medication orders with start date of 9/8/21 for Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 6 hours…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and interviews, the facility failed to maintain a safe, clean, comfortable, and homelike environment on 3 of 3 resident units and in the facility's laundry room. Findings: On 7/11/2022, at 12:20 p.m., during observation of laundry room, with the Director of Environmental Services (EVS) and an EVS worker; there was a light to moderate level of dust on most flat surfaces in the room. Observed very heavy level of dust on top of the top of all washing machines and dryers. Both employees stated that there is no cleaning schedule for the area, and there is no list of things to be done/cleaned. This was confirmed with the Director of Environmental Services at that time. On 7/13/2022, at 12:00 p.m., during tour of the facility with the Director of Environmental Services and the Administrator the following was observed and confirmed at the time of the tour: First Floor findings: Resident room [ROOM NUMBER] - 2 stained ceiling tile Resident room [ROOM NUMBER] - 1 stained ceiling tile…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 1 of 2 Residents (R) reviewed for new admissions (R72). Findings: Review of facility policy Care Planning revised 2/17 states, . Care, treatment, and services are planned to ensure that they are appropriate to the resident's needs, goals and preferences. Therefore, it is the policy of St. [NAME] Health Care Facility to provide an individualized, interdisciplinary plan of care for all residents that is appropriate to the resident's needs, strengths, preferences, limitations, and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals with the resident that are reasonable and measurable . Within forty-eight (48) hours of admission, a baseline care plan is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review and policy review the facility failed to update/implement a care plan in the area of respiratory for 1 of 23 residents (R) reviewed for comprehensive care plans. (R65). Findings: Review of facility policy Care Planning revised 2/17 states, . Care, treatment, and services are planned to ensure that they are appropriate to the resident's needs, goals and preferences. Therefore, it is the policy of St. [NAME] Health Care Facility to provide an individualized, interdisciplinary plan of care for all residents that is appropriate to the resident's needs, strengths, preferences, limitations, and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals with the resident that are reasonable and measurable .The plan of care shall be individualized, based on the diagnosis, resident assessment and personal goals of the resident and his/her family . R65 was originally admitted to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow their Elopement/Missing Resident policy and procedure for 1 of 1 sampled resident's. (#1) Finding: The facilities Elopement/Missing Resident policy and procedure directs staff to assess the resident upon admission for their risk of elopement. Resident #1 was admitted to the facility on [DATE]. On 7/11/22 a surveyor reviewed Resident #1's clinical record. Resident #1's clinical record lacked evidence that an elopement assessment was completed upon admission. On 7/12/22 at 1:55 p.m., during an interview with the Director of Nursing (DON), the surveyor confirmed that an Elopement assessment was not completed.

Based on observations, interviews and policy review the facility failed to ensure foods were dated and labeled in, the reach in freezer, dry storage room and walk in freezer. In addition, the facility failed to discard outdated and obvious freezer burned food on 1 of 3 survey days. Findings: Review of provided Dining Services Storage Policy, undated states, Leftover food that is to be put in the freezer for use again must be used within 90 days of date it was put into the freezer. If an item is open from the freezer, you must label item with what it is and an open on date. Item will be used by the expiration date on package if there is no expiration date on the package item will need to be used within 90 days. Review of facility policy Receiving and Storing of Food and Supplies reviewed 2/18 states, .Unserved foods from previously prepared menus must be discarded after ninety-six (96) hours. Foods that may be frozen safely, such as meat, may be frozen, retained and used within 90 days . During an initial walk through of the kitchen on 7/11/22 at 9:17 a.m. the following was observed:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure a care plan was updated to reflect the resident's current needs in the area of infection control for 1 of 18 sampled residents (#42). Finding: On 11/18/19 at 9:30 a.m., a surveyor observed the entrance to Resident #42's room was posted with signage instructing to stop and check with nurse before entering. The surveyor also observed personal protective equipment (PPE) hanging from the entrance door. On 11/18/19 at approximately 10:00 a.m., in an interview with the charge nurse, the surveyor asked if any residents were currently on infection control precautions. The charge nurse stated Resident #42 required contact precautions for VRE (Vancomycin Resistant Enterococcus) in his/her urine. On 11/19/19 at 11:50 a.m., in an interview with a Certified Nurses Aide-Medications (CNA-M), the surveyor asked what type of precautions the resident requires. The staff stated he/she's on precautions to prevent him/her from getting an infection.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.