Inspection Reports for
St. Ann’s Home
2161 Leonard St NW, Grand Rapids, MI 49504, MI, 49504
Back to Facility Profile1 Report
Inspection Report — Oct 2, 2023
Original Licensing
Date: Oct 2, 2023
Visit Reason
Original license application for a home for the aged facility.
Findings
The facility was found to be in substantial compliance with the public health code and administrative rules regulating home for the aged facilities.
4 CMS Surveys
Inspection Report — Nov 22, 2024
Complaint Investigation
Date: Nov 22, 2024
Visit Reason
Investigation of a complaint received on 2024-11-22 about psychotropic medication use and infection prevention and control.
Complaint Details
Psychotropic medication use without proper consents and extended PRN orders: established. Infection prevention failures including PPE and hand hygiene: established.
Findings
The facility failed to ensure appropriate use and documentation of psychotropic medications for 2 residents, including lack of informed consents and extended PRN orders beyond 14 days without documented rationale. The facility also failed to adhere to infection prevention standards, including proper use of personal protective equipment for enhanced barrier precautions and hand hygiene during meal service, increasing risk of cross-contamination.
Deficiencies (2)
F 0758 Implement gradual dose reductions and non-pharmacological interventions prior to initiating or continuing psychotropic medication; PRN orders must be limited and informed consents obtained. The facility failed to ensure PRN psychotropic medications did not extend beyond 14 days without documented rationale and lacked consents for medications for Residents #23 and #27.
F 0880 Provide and implement an infection prevention and control program. The facility failed to ensure proper personal protective equipment use for enhanced barrier precautions for Resident #6 and failed to perform hand hygiene during dining and meal service, increasing risk of cross-contamination.
Report Facts
PRN psychotropic medication duration limit: 14
Inspection Report — Jan 11, 2024
Complaint Investigation
Date: Jan 11, 2024
Visit Reason
Investigation of a complaint received on 2024-01-09 about resident care, medication administration, accident hazards, respiratory care, dementia care, medical records, infection control, and immunizations.
Complaint Details
Call light accessibility: established. Medication administration documentation: established. Accident hazards and supervision: established. Respiratory care oxygen tubing maintenance: established. Dementia care interventions: established. Medical records accuracy: established. Infection control for respiratory equipment: established. Pneumococcal vaccination offering: established.
Findings
Multiple deficiencies were found including failure to ensure call light accessibility, improper medication administration documentation, inadequate supervision and safety interventions, failure to maintain and change oxygen tubing per physician orders, failure to develop and implement person-centered dementia care interventions, incomplete and inaccurate medical records, failure to implement infection control standards for respiratory equipment storage, and failure to offer pneumococcal vaccine to eligible residents.
Deficiencies (8)
F 0558 Reasonably accommodate the needs and preferences of each resident: Resident #198's call light was placed out of reach, preventing her from calling for assistance.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: RN Q documented medication administration prior to giving medications to Residents #45 and #18.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: Resident #12 was transported in a wheelchair without foot pedals, and Resident #8 wandered unsupervised into other residents' rooms and off the unit.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: Oxygen tubing for Residents #14 and #36 was not changed weekly as ordered and was stored without protective barriers, increasing infection risk.
F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia: Resident #8's care plan lacked comprehensive interventions for wandering, disorientation, and reassurance, resulting in worsening symptoms and emotional distress.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: Residents #14 and #36 had incomplete and inaccurate medical records regarding oxygen therapy documentation.
F 0880 Provide and implement an infection prevention and control program: Residents #36 and #198's respiratory equipment was stored without protective barriers or proper infection control measures.
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: Five residents (#6, #11, #14, #41, and #44) were not offered the pneumococcal vaccine despite eligibility.
Inspection Report — May 31, 2023
Date: May 31, 2023
Visit Reason
Not stated.
Findings
No health deficiencies found.
Inspection Report — Jan 25, 2023
Complaint Investigation
Date: Jan 25, 2023
Visit Reason
Investigation of a complaint received on 2023-01-25 about failure to provide Skilled Nursing Facility Advanced Beneficiary Notice, respiratory care, food safety, and sanitary environment.
Complaint Details
Failure to provide SNF ABN forms: established. Inadequate cleaning and storage of CPAP equipment: established. Improper food storage and labeling: established. Unsanitary nursing home environment: established.
Findings
Multiple deficiencies were found including failure to provide required SNF ABN forms, inadequate cleaning and storage of CPAP equipment, improper food storage and labeling, and unsanitary conditions in the nursing home environment.
Deficiencies (4)
F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered: the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for 2 of 3 residents reviewed, due to staff turnover and lack of training.
F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to clean and store CPAP equipment according to policy for Resident #6, increasing risk of respiratory infection.
F 0812 Procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to effectively label and monitor expiration dates, keep food and non-food contact surfaces clean, maintain freezer cleanliness, and properly store food products.
F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: the facility failed to maintain a sanitary environment, including visibly soiled equipment, furniture, bathrooms, and shared resident equipment, increasing risk of infection and cross-contamination.
Loading inspection reports...
