Inspection Reports for
Saint Anne Home and Retirement Community

The visit was complaint-related due to an incident on 9/8/25 where Resident B was transferred alone by QMA 2 using a Sara lift, contrary to policy requiring two staff. The complaint was substantiated by interviews and record review.

The facility failed to ensure that mechanical lift transfers were performed with the required two staff members, resulting in Resident B sustaining a left humerus fracture during a transfer by a single staff member. Interviews and record reviews confirmed the deficiency in staff competency and adherence to policy.

Saint Anne Home was found in compliance with NFPA 101A Chapter 4 Fire Safety Evaluation System for Health Care Occupancies and achieved a passing score on the FSES survey. However, the facility failed to ensure that 2 of 2 exit stairways had at least 50 percent of the exits leading directly to the outside, which could affect staff and residents.

The facility was found not in compliance with several Life Safety Code requirements including stairway exits not discharging directly outside, exit signage lacking continuous illumination, and staff not trained on hood fire suppression activation. Corrective actions and plans of correction were submitted with completion dates of April 7, 2025.

The facility failed to monitor water temperatures in storage tanks and did not perform routine legionella testing as required by federal guidelines. Temperature logs for 2024 showed no recorded values, and no legionella testing records were available. The facility's policy on water management for legionella was not followed.

Complaint IN00453718 was investigated with no deficiencies related to the allegations cited.

No deficiencies related to the complaint allegations were cited. The facility failed to ensure water temperatures in the water storage tanks were monitored and legionella testing was performed routinely as required by policy. The facility sent water samples for legionella testing and implemented a plan to test annually at multiple locations with ongoing monitoring through quality assurance meetings. The facility was found to be in compliance with state residential licensure requirements.

This citation relates to Complaint IN00440091. The complaint was substantiated based on interviews, record reviews, and confirmation from Doordash and facility investigation.

The facility failed to ensure residents were free from misappropriation of property when CNA 2 was found to have made unauthorized Doordash purchases using Resident B's credit card. The facility initiated an investigation, confirmed the charges matched CNA 2's name and address, and a police report was filed. CNA 2 denied the allegations, blaming a neighbor.

Complaint IN00440091 was substantiated with federal/state deficiencies cited at F602 related to misappropriation of Resident B's property. Complaint IN00439077 had no deficiencies cited.

The facility failed to ensure residents were free from misappropriation of property, specifically involving fraudulent charges made on Resident B's credit card by a Certified Nurse Aide (CNA 2). An investigation confirmed CNA 2 made unauthorized purchases using Resident B's credit card information. The facility implemented corrective actions including secured storage for valuables, resident and family education, staff in-service training, and ongoing monitoring.

Saint Anne Home was found in compliance with NFPA 101A Chapter 4 for Health Care Occupancies and achieved a passing score on the FSES survey. However, the facility failed to ensure that 2 of 2 exit stairways had at least 50 percent of the exits leading directly to the outside, which could affect staff and residents. This deficiency was noted but correction was obviated by the passing FSES score.

The facility was found not in compliance with certain Life Safety Code requirements, including issues with self-closing doors in a hazardous storage room and exit stairways not leading directly outside. The Emergency Preparedness survey found the facility in compliance.

This citation relates to Complaint IN00424824. The complaint involved allegations of physical abuse of Resident D by Qualified Medication Aide (QMA) 4, confirmed by video review, staff interviews, and incident reports.

The facility failed to ensure residents were free from physical abuse for 1 of 3 residents reviewed (Resident D). Video evidence and staff statements showed that QMA 4 attempted to redirect Resident D, who became agitated and combative, resulting in Resident D falling after a physical struggle. The Director of Nursing and other staff confirmed the incident and reviewed relevant documentation and policies.

Complaint IN00424824 was substantiated with federal/state deficiencies cited related to abuse. Complaint IN00425355 was not substantiated with no deficiencies cited.

The facility failed to ensure residents were free from physical abuse for one of three residents reviewed (Resident D). Video evidence and staff interviews documented an incident where Resident D was physically handled inappropriately by a Qualified Medication Aide, resulting in the resident falling and being scolded. The facility implemented corrective actions including staff in-service training on abuse and monitoring to prevent recurrence.

The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to stairways not discharging directly to the outside as required.

The facility was found generally in compliance with NFPA 101A standards; however, a deficiency was identified where both exit stairways did not lead directly to the outside, which could affect staff and residents.

The facility was found deficient in multiple areas including resident dignity and privacy, accurate assessments, timely response to call lights, communication and hearing loss management, pressure ulcer care, fall prevention, respiratory care, pain management, trauma-informed care, medication labeling and storage, and kitchen sanitation.

The facility was found to have multiple deficiencies including failure to maintain resident dignity, privacy, accurate assessments, timely call light response, communication needs, pressure ulcer treatment, fall prevention, respiratory care, pain management, trauma-informed care, medication labeling and storage, and kitchen sanitation. Corrective actions and systemic changes were planned or implemented for each deficiency.

Complaint IN00396574 was substantiated with no deficiencies cited. Complaint IN00396697 was substantiated with deficiencies cited at F600, F607, and F610 related to abuse by a staff member (Employee 3) who kissed Resident J on the lips. The investigation was incomplete, missing interviews with other residents and staff on the affected unit.

The facility failed to ensure residents were free from staff abuse, specifically involving a male staff member (Employee 3) who gave a resident (Resident J) a hug and kissed her on the lips. The facility also failed to implement policies and procedures to prevent abuse, and failed to conduct a thorough investigation of the abuse allegation. Employee 3 resigned following the incident. The resident was not distressed but concerned about others. The investigation did not include interviews with all potentially affected residents or staff.