St Ann's Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to develop a person-centered care plan related to hospice services for 1 (Resident #10) of 12 residents reviewed for person-centered care planning resulting in the potential for unmet care needs.Findings include:Resident #10Review of an admission Record revealed Resident #10 was a male who was originally admitted to the facility on [DATE] and had pertinent diagnoses including: Alzheimer's disease and dementia.Review of Order Summary for Resident #10 revealed .ADMIT to (Name Omitted) hospice dx: (diagnosis) Alzheimer's disease. with a start date of 10/31/25Review of Care Plan for Resident #10 revealed no noted care plan related to collaboration of care between the facility and (Name Omitted) hospice services.In an interview on 1/22/26 at 2:13 PM, Hospice Registered Nurse (H/RN) DD reported Resident #10 had been on services for a few months this time, he had previously had services as well. H/RN DD reported Resident #10 had a separate care plan that was…

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 observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer in 1 (Resident #9) of 2 reviewed for pressure ulcers, resulting in the development of a pressure wound on Resident #9's right ankle.Findings include:Resident #9Review of an admission Record revealed Resident #9 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses including: Alzheimer's disease (progressive mental deterioration), dementia (loss of cognitive function), and anxiety disorder.Review of a Minimum Data Set (MDS) assessment for Resident #9, with a reference date of 8/4/25 revealed a Self-Care Assessment - Mobility- roll left to right- Substantial/maximal assistance, sit to laying substantial/maximal assistance, and laying to sitting on bed side dependent.Review of Care Plan for Resident #9 revealed .has an ADL (activities of daily living) self-care performance deficient r/t (related to) Alzheimer's, dementia.intervention: bed mobility; one…

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 observation, interview, and record review the facility failed to maintain infection control practices and implement enhanced barrier precautions (EBP) related to wound care for 1 (Resident #9) of 3 resident reviewed for wound care resulting in the potential for cross contamination, disease transmission, and the introduction of infection.Findings include:Resident #9Review of an admission Record revealed Resident #9 was a female who was originally admitted to the facility on [DATE] and had pertinent diagnoses including: Alzheimer's disease (progressive mental deterioration), dementia (loss of cognitive functioning), and anxiety disorder.Review of Centers for Disease Control and Prevention (CDC) dated March 20, 2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard…

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 observation, interview and record review, the facility failed to identify post-traumatic stress disorder (PTSD) triggers and develop individualized care plan interventions to mitigate triggers for 1 resident (Resident #22) of 1 resident reviewed for trauma informed care, resulting in the potential for re-traumatization due to staff not being informed and knowledgeable of the resident's past trauma. Findings include: Resident #22 (R22) Review of the admission Record and Minimum Data Set (MDS) dated [DATE] revealed R22 admitted to the facility on [DATE] with diagnoses including PTSD, depression, bipolar disorder (mood swings ranging from depressive lows to manic highs, chronic respiratory failure and Takotsubo Syndrome (sudden temporary weakening of the muscular portion of the heart which appears after a significant stressor, either physical or emotional). Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which indicated R22 was cognitively intact (13 to 15 cognitively intact).…

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 observation, interview and record review, the facility failed to ensure 1. as needed (PRN) medications did not extend greater than 14 days, 2. continued indication for use of psychotropic and antipsychotic medications, and 3. obtain informed consents for medications, for 2 (R23 and R27) of 5 residents reviewed for unnecessary medications, resulting in the risk of serious side effects and adverse reactions from potentially unnecessary medications. Findings include: According to https://www.aafp.org/afp/2000/0301/p1437.html, in an article titled, Appropriate Use of Psychotropic Drugs in Nursing Homes, revealed, Because treatment with psychotropic medications is indicated only to maintain or improve functional status, diagnoses and specific target symptoms or behaviors must be documented, and the effectiveness of drug therapy must be monitored. Resident #23: (R23) Review of a Face Sheet for R23 revealed she was admitted to the facility on [DATE] with pertinent diagnoses of dementia, adjustment disorder,…

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, observation, and record review, the facility failed to adhere to profession standards of infection prevention for 1. the proper personal protective equipment use for enhanced barrier precautions for 1 of 1 resident (Resident #6) and 2. hand hygiene during dining and meal service, resulting in the increased potential for cross-contamination, bacterial harborage, and placing a vulnerable population at high risk for the transmission/transfer of pathogenic organisms and cross contamination between residents. Findings include: 1. Enhanced barrier precautions Review of Centers for Disease Control and Prevention (CDC) dated March 20,2024, revealed, .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities .EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during…

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, the facility failed to offer and provide the pneumococcal vaccine for 5 (Resident #6, #11, #14, #41, and #44) of 5 residents reviewed for immunizations, resulting in a delay in the residents to be given the opportunity to receive or decline the pneumococcal vaccination. Findings include: According to the Centers for Disease Control and Prevention (CDC) PCV20 Vaccination for Adults 65 Years and Older dated 02/09/23, revealed, .Routine vaccination: Adults 65 years or older who have- Previously received both PCV13 and PPSV23, AND PPSV23 was received at age [AGE] years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose . www.cdc.gov/vaccines/hcp/admin/downloads/job-aid-SCDM-PCV20-508.pdf Resident #6: Review of an admission Record revealed Resident #6 was a female with pertinent diagnoses which included pressure ulcer of sacral region (above the tailbone), adult failure to thrive, anemia, dementia, kidney…

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 observation, interview, and record review, the facility failed to ensure access to a call light in 1 of 12 sampled residents (Resident #198) reviewed for call light placement, resulting in the inability to call for assistance and the potential for unmet care needs. Findings include: According to https://www.ncbi.nlm.nih.gov, .Call light technology serve as a means of communication for patients to their care providers that are outside of the patient's room. This technology is a direct link to getting their needs met and the care provided by nurses . Resident #198: Review of an admission Record revealed Resident #198 was a female with pertinent diagnoses which included fracture of femoral neck right femur, hemiplegia (paralysis) and hemiparesis (weakness) of left side following stroke, diabetes, history of falling and use of blood thinners. Review of Care Plan revised on 12/29/23, revealed the focus, .(Resident #198) at risk for falls r/t (related to); falls in community, fracture of right femur,…

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 observation, interview, and record review, the facility failed to follow professional standards of practice for documentation of medication administration in 2 of 10 residents (Resident #45 & #18) reviewed for medication administration, resulting in the potential for medication errors. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Accessed from: Kindle Locations 24106-24108). Elsevier Health Sciences. Kindle Edition. Review of the policy/procedure Medication Administration, dated 12/1/23, revealed .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to…

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 provide adequate supervision and safety interventions for 2 of 13 residents (Resident #8 and Resident #12) reviewed for accident hazards/supervision, resulting in Resident #8 wandering into other resident's rooms as well as off the unit, and Resident #12 being transported in a wheelchair without the use of footrests. Findings include: Resident #8 Review of a admission Record dated 6/29/23 revealed Resident #8 was admitted to the facility with the following pertinent diagnoses: dementia (a condition characterized by progressive or persistent loss of intellectual functioning), posterior subcapsular cataract (eye condition causing difficulty reading and reduced vision in brightly light areas), and depression. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored 5/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired. Section E of the MDS…

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 observation, interview, and record review, the facility failed to maintain and change oxygen tubing per physician order in 2 of 3 residents (Resident #14 & #36) reviewed for respiratory care, resulting in the potential for the development and spread of respiratory illness. Findings include: Review of the policy/procedure Oxygen Administration, dated 12/1/23, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences .Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include .Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated . Resident #14 Review of an admission Record revealed Resident #14 was a female, with pertinent diagnoses which included obstructive lung disease, diabetes, shortness of breath, and chronic bronchitis. Review of an Order Summary Report for Resident #14 revealed the active…

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 observation, interview, and record review the facility failed to develop and implement person centered dementia care interventions to address wandering, disorientation, and reassurance for 1 of 13 residents (Resident #8) reviewed for dementia care, resulting in Resident #8 experiencing worsening wandering, disorientation to his room, verbal aggression from another resident, and emotional distress. Findings include: Review of an admission Record dated 6/29/23 revealed Resident #8 was admitted to the facility with the following pertinent diagnoses: dementia (a condition characterized by progressive or persistent loss of intellectual functioning), posterior subcapsular cataract (eye condition causing difficulty reading and reduced vision in brightly light areas), and depression. Review of a Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored 5/15 on a Brief Interview for Mental Status (BIMS) assessment which indicated the resident was severely cognitively impaired. Section GG of 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 observation, interview, and record review, the facility failed to maintain complete and accurate medical records in 2 of 13 residents (Resident #14 & #36) reviewed for accuracy of medical records, resulting in inaccurate treatment records and the potential for providers to not have an accurate picture of resident status and condition. Findings include: According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Accessed from: Kindle Locations 24106-24108). Elsevier Health Sciences. Kindle Edition. Review of the policy/procedure Oxygen Administration, dated 12/1/23, revealed .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and…

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 observation, interview, and record review the facility failed to implement infection control standards for storage of respiratory care equipment for 2 of 8 residents (Resident #36, #198), reviewed for infection control practice, resulting in the potential for the spread of disease, increase the risk of infection and bacterial harborage. Findings include: Resident #36: Review of an admission Record revealed Resident #36 was a female with pertinent diagnoses which included dementia, anxiety, respiratory failure, impaired coordination, neuropathy (weakness, numbness, and pain from nerve damage usually in hands and feet), arthritis, aspiration pneumonia, achalasia of cardia (rare swallowing disorder), abnormal movements, and sleep apnea. Review of current Care Plan for Resident #36, revised on 10/19/23, revealed the focus, .(Resident #36) has oxygen therapy r/t (related to) CHF (congestive heart failure) . with the intervention .OXYGEN SETTINGS: O2 via nasal prongs/mask @ 2-4L PRN (as needed) . Review of Orders dated 10/22/23, revealed, .Oxygen Tubing - change weekly and date q…

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.