Inspection Reports for St. Ann’s Home
2161 Leonard St NW, Grand Rapids, MI 49504, MI, 49504
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
44% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 22, 2024
Visit Reason
The inspection was conducted based on complaints related to trauma-informed care, psychotropic medication use, infection prevention, and hand hygiene practices at the facility.
Complaint Details
The investigation was complaint-driven focusing on trauma-informed care deficiencies, psychotropic medication management, and infection control practices including PPE use and hand hygiene.
Findings
The facility failed to identify PTSD triggers and develop individualized care plans for trauma-informed care, improperly managed psychotropic medications including PRN orders exceeding 14 days without proper documentation or consents, and did not adhere to infection prevention standards including improper use of personal protective equipment and inadequate hand hygiene during meal service.
Deficiencies (3)
Failed to identify PTSD triggers and develop individualized care plan interventions for Resident #22, resulting in potential re-traumatization.
Failed to ensure PRN psychotropic medications did not extend beyond 14 days without proper indication, continued indication, or informed consents for Residents #23 and #27, risking serious side effects.
Failed to provide and implement an infection prevention and control program, including improper use of personal protective equipment for enhanced barrier precautions and inadequate hand hygiene during dining and meal service.
Report Facts
PRN Lorazepam administrations: 9
PRN Lorazepam administrations: 1
PRN ABH cream applications: 7
PRN Lorazepam administrations: 6
PRN Haloperidol administrations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Y | Licensed Practical Nurse | Reported knowledge of Resident #22's PTSD triggers and medication monitoring for Resident #27. |
| ADON C | Assistant Director of Nursing | Reported uncertainty about PTSD assessment or care plan for Resident #22. |
| Administrator A | Nursing Home Administrator | Reported Social Worker acknowledged missing PTSD care plan for Resident #22. |
| SSC K | Social Service Coordinator | Questioned continued use of ABH cream for Resident #23. |
| RN P | Hospice Registered Nurse | Reported hospice medication management and lack of consents for Resident #23's psychotropic medications. |
| DON B | Director of Nursing | Reported facility policies on psychotropic medication consents and education on infection control. |
| Pharmacist O | Pharmacist | Reported PRN psychotropic medication duration regulations and reminders to providers. |
| Director Q | Director of Environmental Services | Reported PPE use policies for enhanced barrier precautions. |
| CNA II | Certified Nursing Assistant | Observed and reported hand hygiene practices during meal service. |
| CNA X | Certified Nursing Assistant | Observed assisting multiple residents with eating without hand hygiene between residents. |
| RN M | Registered Nurse | Observed assisting residents with eating without hand hygiene between residents. |
| CNA F | Certified Nursing Assistant | Reported expectations for hand hygiene during meal service. |
| CNA R | Certified Nursing Assistant | Reported hand hygiene and glove use expectations during meal assistance. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 11, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident care, safety, medication administration, infection control, and immunization practices.
Findings
The facility was found deficient in multiple areas including failure to ensure call light accessibility for residents, improper medication administration documentation, inadequate supervision and safety interventions for residents at risk of falls and wandering, failure to maintain and change oxygen tubing per physician orders, incomplete and inaccurate medical records, failure to implement infection control standards for respiratory equipment storage, and failure to offer pneumococcal vaccinations to eligible residents.
Deficiencies (8)
Failure to ensure access to a call light for Resident #198, resulting in inability to call for assistance and potential unmet care needs.
Failure to follow professional standards for documentation of medication administration in Residents #45 and #18, documenting medications as given prior to administration.
Failure to provide adequate supervision and safety interventions for Residents #8 and #12, resulting in wandering and unsafe wheelchair transport without footrests.
Failure to maintain and change oxygen tubing weekly as ordered for Residents #14 and #36, with tubing observed to be over four weeks old.
Failure to develop and implement person-centered dementia care interventions for Resident #8, resulting in worsening wandering, disorientation, verbal aggression from another resident, and emotional distress.
Failure to maintain complete and accurate medical records for Residents #14 and #36, resulting in inaccurate treatment records and potential for providers to lack accurate resident status.
Failure to implement infection control standards for storage of respiratory care equipment for Residents #36 and #198, with equipment not stored in protective barriers, increasing risk of infection.
Failure to offer and provide pneumococcal vaccine (PCV20) to 5 residents (#6, #11, #14, #41, #44) resulting in delayed opportunity to receive or decline vaccination.
Report Facts
Residents reviewed for medication administration: 10
Residents reviewed for accident hazards/supervision: 13
Residents reviewed for respiratory care: 3
Residents reviewed for infection control practice: 8
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA Z | Certified Nursing Assistant | Named in call light and hydration assistance observation for Resident #198 |
| RN Q | Registered Nurse | Observed medication preparation and documentation for Residents #45 and #18 |
| LPN K | Licensed Practical Nurse | Interviewed regarding medication documentation standards |
| LPN C | Licensed Practical Nurse | Interviewed regarding medication documentation standards |
| DON B | Director of Nursing | Interviewed regarding medication documentation and safety concerns |
| CNA BB | Certified Nursing Assistant | Observed pushing Resident #12 in wheelchair without foot pedals |
| LPN CC | Licensed Practical Nurse | Interviewed regarding wheelchair safety and foot pedals |
| Infection Preventionist R | Infection Preventionist | Interviewed regarding infection control practices and oxygen tubing care |
| CENA G | Certified Nursing Assistant | Interviewed regarding supervision and wandering of Resident #8 |
| SSC S | Social Services Coordinator | Interviewed regarding wandering and behavioral interventions for Resident #8 |
| CENA J | Certified Nursing Assistant | Interviewed regarding Resident #8 wandering and interactions with other residents |
| NHA A | Nursing Home Administrator | Interviewed regarding Resident #8 wandering and safety concerns |
| CNA EE | Certified Nursing Assistant | Observed exiting Resident #36's room with oxygen equipment |
| LPN CCC | Licensed Practical Nurse | Interviewed regarding CPAP machine cleaning and storage |
| IFP S | Infection Preventionist | Interviewed regarding vaccination audits and pneumococcal vaccine efforts |
| FM AA | Family Member | Interviewed regarding Resident #8's condition and visits |
| AA E | Activity Assistant | Interviewed regarding Resident #8's activity preferences |
Inspection Report
Renewal
Census: 23
Capacity: 95
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
The inspection was conducted as a renewal inspection to determine compliance with applicable licensing statutes and rules for St. Ann's Home.
Findings
The facility was found to be in substantial compliance with the public health code and administrative rules regulating home for the aged facilities. The licensing study determined substantial compliance and recommended issuance of a regular license.
Report Facts
Number of staff interviewed and/or observed: 15
Number of residents interviewed and/or observed: 23
Capacity: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ann Auger | Authorized Representative | Named in identifying information |
| Dana Prince | Administrator | Named in identifying information |
| Lauren Wohlfert | Licensing Staff | Signed the report and recommendation |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 31, 2023
Visit Reason
The inspection was conducted as an annual survey of St Ann's Home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected were unknown.
Inspection Report
Routine
Deficiencies: 4
Date: Jan 25, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to Medicaid/Medicare notifications, respiratory care, food safety, and sanitary conditions in the nursing home.
Findings
The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices to residents, failed to properly clean and store CPAP equipment, did not maintain proper food labeling and storage, and failed to maintain sanitary conditions in resident areas and shared equipment, resulting in potential risks for financial liability unawareness, respiratory infections, foodborne illness, and increased infections.
Deficiencies (4)
Failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) detailing estimated charges for continued services to 2 of 3 residents reviewed.
Failed to clean and store CPAP equipment according to facility policy for 1 resident, increasing risk of respiratory infection and distress.
Failed to procure food from approved sources and maintain proper storage, labeling, and cleanliness, increasing risk of foodborne illness.
Failed to maintain a sanitary environment in nursing home areas, including soiled equipment and surfaces, increasing risk of infections and cross-contamination.
Report Facts
Residents reviewed for SNF ABN notification: 3
Residents reviewed for respiratory care: 2
Cans of pineapple juice removed: 3
Date of last Part A Service for Resident #42: Sep 23, 2022
Date of last Part A Service for Resident #4: Dec 9, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator A | Nursing Home Administrator | Reported error in SNF ABN form completion and staff turnover affecting form completion. |
| Director of Nursing B | Director of Nursing | Reported lack of documentation for CPAP cleaning and facility policy on CPAP maintenance. |
| Finance Representative W | Finance Representative | Reported residents should have received SNF ABN forms. |
| Certified Nursing Assistant Z | Certified Nursing Assistant | Reported nurses responsible for cleaning and maintenance of CPAP machines. |
| Registered Nurse Y | Registered Nurse | Reported CPAP masks should be cleaned with soap and water but was unaware of cleaning responsibility or policy. |
| Dietary Manager U | Dietary Manager | Observed food safety violations and instructed staff to clean utensil drawer. |
| Registered Dietary Technician V | Registered Dietary Technician | Reported need to review food labeling process. |
| Housekeeper O | Housekeeper | Reported cleaning responsibilities for resident rooms and shared equipment. |
| Certified Nursing Assistant G | Certified Nursing Assistant | Reported responsibility to sanitize shared equipment between uses. |
| Infection Control Preventionist-Director of Nursing B | Infection Control Preventionist-Director of Nursing | Reported cleaning expectations for shared equipment and surfaces. |
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