Inspection Reports for
Homestead Assisted Living Centers Inc – St. Anthony

.405.02.c. Prohibited applications: a mini refrigerator was plugged into a relocatable power tap, which is a prohibited application, and the resident had switched it from the wall to the power tap.

.320 Negotiated service agreement (NSA) requirements: the facility did not develop a sufficient interim care plan for a resident nor update a care plan when needs changed, including missing documentation of oxygen use, pain pump, and AV shunt for Resident #5 and self-administered supplements for Resident #3.

.330.15 Fire and life safety records: the facility could not provide documentation of the 5-year sensitivity fire alarm system inspection; the last inspection was dated 4/29/19 and the most recent documentation was not located.

.155.01 Relocation agreements: the facility has only one relocation agreement instead of the required two, and agreements must be reviewed annually (previously cited 7/18/2022).

.404 Fire and life safety standards: facility failed to maintain monthly visual inspections of wet system pressure gauges and kitchen hood ventilation filters had gaps allowing grease-laden vapors to bypass filtration.

.405.01.a Electrical installations and equipment: use of prohibited multi-plug adapters to power numerous devices was observed.

.405.04 Fuel-fired heating: last inspection was on 2/16/2021; fuel-fired heating devices must be inspected, serviced, and cleaned annually by a qualified professional (previously cited 7/18/2022).

.410 Requirements for emergency actions and fire drills: facility failed to document the designated point of assembly for evacuation/fire drills (previously cited 7/18/2022).

.215.01 Administrator Responsibility: the administrator and facility nurse did not follow the facility's medication policy requiring review of medications to ensure physician orders matched medications taken by residents.

.215.08.b Investigation within Thirty Days: the administrator did not conduct an investigation within 30 days after Resident #4 received the wrong dose of imipramine hcl, multiple falls, and a skin tear on their left hand.

.215.08.e Corrective Action: the facility did not ensure effective corrective action was implemented to prevent recurrence of falls for Residents #3, #4, and #6, as corrective actions were not monitored for effectiveness.

.215.08.f Notification to Licensing Agency within One Business Day: the facility failed to notify Licensing and Certification within one business day after Resident #4's fall resulting in a fractured right hip and Resident #5's fall causing a large gash requiring hospital treatment.

.300.01 Licensed Registered Nurse (RN): the facility nurse did not complete initial nursing assessments for Residents #1, #3, #4, and #5.

.300.02 Licensed Nurse: the facility nurse did not review and implement all orders for Residents #3, #4, #5, and #6, leading to incorrect transcription and misadministration of medications, including Resident #4 receiving wrong doses of imipramine hcl resulting in hospitalization.

.305.02.b Current Medication Orders and Treatment Orders: the facility failed to ensure medications were available and given as ordered for Residents #3, #4, #5, and #6, including missed doses and incorrect transcription of medications.

.305.03 Resident Health Status: the facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, such as a skin tear and swelling in Resident #3's left hand.

.310.04.e Psychotropic or Behavior Modifying Medication: Residents #1 and #2 were taking psychotropic medications longer than six months without required six-month medication reviews including behavioral updates.

.319 Comprehensive Assessment Requirements: Residents #1 and #4 did not have comprehensive assessments completed prior to admission or readmission, including after Resident #4's hip fracture.

.320 Negotiated Service Agreement (NSA) Requirements: the facility did not develop or update interim care plans and NSAs for Residents #4, #5, and #6 to reflect current care needs and hospice services.

.310.01 Medication Distribution System: the facility had bulk bottles of medications not labeled for individual residents, contrary to pharmacist or facility nurse labeling requirements.

.520 Requirements to Protect Residents from Inadequate Care: the facility failed to provide appropriate assistance and monitoring of medications for Residents #3, #4, #5, and #6, resulting in incorrect medication administration, inadequate care, and potential harm to all residents.

.155.01 Relocation agreements: only one documented relocation agreement dated 2011 with one alternate location; facility must have at least two agreements reviewed annually.

.404 Fire and life safety standards for existing buildings licensed for seventeen or more residents and multi-story buildings: no documentation for last full trip of dry fire suppression system; anti-freeze loop expansion tanks not rated for fire systems; no emergency lighting testing documentation; storage blocking access to riser and electrical panels (corrected on site); no testing or replacement documentation for dry system pendants; no documented annual fire alarm inspection since 2020; no bi-monthly staff training on emergency plan actions (previously cited 7/18/22).

.405.03 Medical gases: oxygen storage not in accordance with NFPA 99; unsecured oxygen cylinders in Room 20; no documented staff inservice on oxygen risks; no policy on misuse of flammable substances and ignition source elimination for respiratory therapy.

.405.04 Fuel-fired heating: no documented annual furnace and fireplace inspection since January/February 2021.

.410 Requirements for emergency actions and fire drills: facility emergency egress and relocation drills not documented to a designated point of assembly.

.305.02.a. Current Medication Orders and Treatment Orders: the facility nurse did not ensure residents' medication orders matched the bubble packs and Medication Administration Records; discrepancies included incorrect dosages and use of as-needed medications as scheduled doses (previously cited 5/7/2021).

.310.01.g. Medication Distribution System: residents did not have their as-needed medications available at all times, including lorazepam for anxiety and nystatin cream for a yeast infection (previously cited 5/7/2021).

.009.05.b New criminal history and background check: the facility did not obtain new criminal history background checks for two staff members whose previous checks were more than three years old.

.215.05 Responsibility for acceptable admissions: the facility admitted and retained residents who required a secured facility along with residents who were cognitively intact and did not require a secured facility, placing residents at risk.

.215.08.f Notification to licensing agency within one business day: the administrator did not report to Licensing and Certification when residents sustained serious injuries requiring hospital evaluation and treatment.

.250.13 Secure environment: the facility was not approved as a secured environment; some exterior doors were unlocked allowing residents with dementia to exit unsupervised, placing them at risk.

.260.07 Toxic chemicals: the facility did not secure all toxic chemicals when cognitively impaired residents were present, including unsecured toilet cleaner and disinfectant.

.300.02 Licensed nurse: the facility nurse did not conduct nursing assessments after residents experienced changes in health status or falls, including multiple falls and bowel issues.

.305.02.a Current medication orders and treatment orders: medication administration records, bubble packs, and provider orders were not congruent, with conflicting instructions and incorrect dosages documented.

.310.01.g Medication distribution system: medications were not available for several residents, including missing as-needed lorazepam, inhalers, and other medications.

.310.03 Controlled substances: controlled substances were not counted daily or accurately reconciled, including morphine, lorazepam, and clonazepam.

.319.03 Nursing assessment: residents were not assessed by nursing prior to or shortly after admission, delaying care and placing residents at risk.

.330.14 As worked schedules: the facility's as worked schedule did not document dates, times, or titles of key facility employees present.

.335.03 Reporting of individual with an infectious disease: the facility did not follow public health or CDC recommendations for COVID-19 prevention, including inadequate visitor screening and mask use.

.520-11 Inadequate care - acceptable admission and retention: the facility admitted and retained residents at risk for elopement in an unsecured environment without appropriate assessments or secure measures, placing residents and others at risk of harm.

.405.01 Medical Gases: Both electrical panels in the main office riser room were blocked by storage and must be maintained with 36" clearance in accordance with NFPA 70, Section 110 (corrected on site 4/10/2019).

.405.01.b Electrical Installations and Equipment: Extension cords and multiple plug adapters are prohibited; a relocatable power tap in the office data/cable TV was daisy-chained into an extension cord.

.410.02 Fire Drills: Facility shall conduct fire drills for each shift each quarter; documented third quarter fire drills in 2018 were missing the p.m. shift.

.415.04 Fire Alarm Smoke Detection System Service and Testing: No record of five year sensitivity testing documentation was on site.

.415.05 Automatic Fire Extinguishing System Service and Testing: Missing quarterly inspection reports (repeat), secured wet system control valves lacked documented monthly inspections, and only one of two semi-annual kitchen hood cleanings/inspections was documented in accordance with NFPA 96 and NFPA 17A.

.405.01 Medical gases: a full size hair dryer in the beauty salon was plugged into a surge protected multiple plug adapter; this was corrected on site and removed by the administrator on 2/15/18.

.405.03 Medical gases: three liquid oxygen cylinders on the back porch were unsecured, including one in room 24; no signage for oxygen in use was present on resident rooms or exterior of the building.

.405.05 Structure, maintenance, equipment to assure safety: no record for emergency light testing at 30 seconds monthly and 90 minutes annually from 2015 to date.

.405.05 Structure, maintenance, equipment to assure safety: exit signs in resident hallways were blocked from view by lighting; exit sign at smoke barrier doors indicated path of common travel is into wall when doors are activated (Chevron has been removed).

.405.07 Exit door locks: exit door at front equipped with magnetic locking arrangement without special locking (Delayed Egress) as allowed under NFPA 101, Chapter 7; facility is not self-declared as full Memory Care unit or secured beds; exit doors in halls have magnetic locks without delayed egress.

.410.02 Fire drills: two missing fire drills for fourth quarter of 2017 on P.M. and Noc shifts.

.415.04 Fire alarm smoke detection system service and testing: missing annual fire alarm inspection; last inspection dated 9/9/16.

.415.05 Automatic fire extinguishing system service and testing: no records for quarterly sprinkler inspections from 2015 to date; no record of last five year internal piping inspection; sprinkler head in janitor closet is corroded.

.305.08 Resident and facility staff education: the facility did not ensure all staff were knowledgeable regarding all residents' care needs, including catheter care, oxygen use, and pressure pad use.

.320 Requirements for the negotiated service agreement: residents' negotiated service agreements were not updated to clearly describe the resident and services to be provided, including insulin therapy, coumadin therapy, diet requirements, and outside agency services (previously cited 6/11/2013).

.350.02 Administrator or designee investigation within thirty days: the administrator did not complete a thorough investigation of a resident with multiple bruises and skin tears and did not document an investigation of all complaints.

.350.04 Written response to complaint within thirty days: the administrator did not provide a written response to all complainants.

.451.02 Snacks: the facility did not offer snacks to residents between breakfast and lunch, lunch and dinner, and at bedtime.

.305.03 Resident health status: the facility nurse did not complete change of condition assessments for all residents with health or mental status changes, including weight loss, low blood pressure, new insulin use, headaches, psychotropic medication addition, bruises, skin tears, and catheter leaks (previously cited 6/11/2013).

.705.02 Written admissions agreement: a resident did not have an admission agreement signed and dated by all required parties.

.711.08 Care notes: care staff did not document an incident when they found a resident with multiple facial bruises and skin tears.

.730.01.e Personnel: two of six staff did not have signed orientation training documents; the facility received technical assistance regarding this rule during the 6/11/2013 survey.