Inspection Report
Plan of Correction
Deficiencies: 0
Nov 27, 2024
Visit Reason
An off-site desk audit was conducted on November 27, 2024, to review all previous deficiencies cited on October 24, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all previous deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 5
Oct 24, 2024
Visit Reason
A recertification survey was conducted at St Antoine Residence Nursing Home from 10/20/2024 through 10/24/2024 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities, including a state licensure and emergency preparedness survey.
Findings
Deficiencies were identified related to pressure ulcer prevention and treatment, physician supervision and orders, food procurement and safety, infection prevention and control, and enhanced barrier precautions. Education and audits were planned to ensure compliance. No Life Safety Code deficiencies were identified.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure residents with pressure ulcers receive necessary treatment and services to promote healing and prevent new ulcers. |
| Facility failed to ensure a Nurse Practitioner provided orders for a resident with acute urinary retention. |
| Facility failed to procure, store, prepare, distribute, and serve food in accordance with professional standards for food service safety. |
| Facility failed to maintain an infection prevention and control program to prevent communicable diseases and infections. |
| Facility failed to maintain Enhanced Barrier Precautions for residents with pressure ulcers and wounds to prevent transmission of multidrug-resistant organisms. |
Report Facts
Deficiency count: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse | Acknowledged failure to offload resident's heels and lack of awareness of urine culture and sensitivity requirement; involved in wound care observations and infection control education. |
| Staff F | Licensed Practical Nurse | Acknowledged failure to offload resident's heels during observations. |
| Staff H | Licensed Practical Nurse | Observed failing to use applicator and proper hand hygiene during wound dressing changes. |
| Staff J | Acknowledged failure to provide order for urine culture and sensitivity. | |
| Staff G | Certified Medication Technician | Failed to wear protective gowns during coccyx dressing change. |
| Director of Nursing Services | Expected staff to follow physician orders for offloading heels and infection control guidelines. | |
| Executive Director | Executive Director | Ultimately responsible to ensure compliance and oversee corrective actions. |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 7, 2024
Visit Reason
A follow-up to a previous investigation survey was conducted at this facility on 02/07/2024 to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no deficiencies were identified during this follow-up survey.
Inspection Report
Annual Inspection
Deficiencies: 9
Jan 12, 2024
Visit Reason
A Recertification Survey was conducted at St. Antoine Residence Nursing Home from 01/08/2024 through 01/12/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including a State licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to investigation of alleged abuse, accident hazards and supervision, colostomy care, nutrition and hydration, nursing staff competencies, dental services, food safety, infection control, and essential equipment. The facility failed to ensure thorough investigations, adequate supervision, proper monitoring, and compliance with policies and procedures in multiple areas.
Severity Breakdown
Level D: 2
Level E: 3
Level F: 3
Level G: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure all alleged violations of abuse were thoroughly investigated for Resident #87 with bruising of unknown origin. | Level D |
| Failure to ensure adequate supervision to prevent falls resulting in hospital transfer for Resident #62. | Level G |
| Failure to provide care consistent with comprehensive care plan for colostomy care for Resident #230. | Level D |
| Failure to maintain acceptable nutritional status for Resident #218. | Level D |
| Failure to ensure sufficient nursing staff competencies and skills for safe resident care for Resident #62. | Level F |
| Failure to assist residents in obtaining routine and emergency dental care for multiple residents. | Level E |
| Failure to ensure food safety requirements including proper labeling, storage, and sanitation in kitchen and food service areas. | Level F |
| Failure to establish and maintain an infection prevention and control program including staff education and PPE use. | Level E |
| Failure to maintain all mechanical, electrical, and patient care equipment in safe operating condition including shower trolleys. | Level E |
Report Facts
Date of survey completion: Jan 12, 2024
Number of residents reviewed for falls: 3
Number of residents reviewed for dental services: 7
Number of positive COVID-19 cases: 7
Resident weights: 249.8
Resident weights: 258.8
Resident weight: 131.9
Resident weight: 120
Resident weight: 121
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Interviewed regarding bruise investigation on 1/12/2024 |
| Director of Nursing Services | Acknowledged injury was not reported or investigated; responsible for ensuring compliance | |
| Staff B | Nursing Assistant | Interviewed about shower trolley use and safety |
| Staff C | Registered Nurse | Interviewed about nursing assessment after fall |
| Staff D | Nursing Assistant | Interviewed about shower trolley incident |
| Staff F | Nursing Assistant | Interviewed about shower trolley safety |
| Director of Therapy | Interviewed about staff requirements for shower trolley assistance | |
| Staff G | Licensed Practical Nurse | Interviewed about staff requirements for shower trolley |
| Staff K | Nursing Assistant | Received infection control education and observed not performing hand hygiene |
| Staff L | Nursing Assistant | Received infection control education and observed not performing hand hygiene |
| Infection Preventionist | Interviewed about infection control expectations | |
| Maintenance Director | Interviewed about shower trolley inspections and maintenance | |
| Food Service Director | Conducted audits and education on food safety | |
| Assistant Food Service Director | Observed food safety violations | |
| Medication Technician | Interviewed about food discard |
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 19, 2022
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on November 18, 2022.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 11
Nov 18, 2022
Visit Reason
A Recertification Survey and complaint investigation survey were conducted from 11/13/2022 through 11/18/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities and state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to Resident Rights/Exercise of Rights, Accuracy of Assessments, Development and Implementation of Comprehensive Care Plans, Services Provided Meeting Professional Standards, Activities of Daily Living, Respiratory/Tracheostomy Care, Drug Regimen Free from Unnecessary Drugs, Storage of Drugs and Biologicals, Assistive Devices, Food Procurement and Safety, and Handling of Resident Funds. The facility failed to ensure residents' rights were respected, assessments were accurate, care plans were comprehensive and implemented, and medication and food safety standards were met.
Complaint Details
Complaint investigation was conducted as part of the recertification survey with ACTS Reference Numbers 86283, 87805, 86055, 87913.
Deficiencies (11)
| Description |
|---|
| Facility failed to care for each resident in an environment that promotes maintenance of residents' dignity during the dining experience. |
| Assessment failed to accurately reflect resident's wandering status. |
| Facility failed to implement a comprehensive person-centered care plan for resident with wandering and elopement risk. |
| Facility failed to ensure services met professional standards for ancillary feeding supplies for residents requiring enteral nutrition. |
| Facility failed to provide necessary care and services to ensure resident's abilities in activities of daily living were maintained. |
| Facility failed to provide respiratory care consistent with professional standards for residents receiving oxygen therapy. |
| Facility failed to ensure resident's drug regimen was free from unnecessary drugs for 2 of 5 residents reviewed. |
| Facility failed to store and label drugs and biologicals in accordance with accepted professional principles. |
| Facility failed to provide special adaptive eating equipment and utensils for residents who required them. |
| Facility failed to ensure food was procured, stored, prepared, distributed and served in accordance with professional standards for food service safety. |
| Facility failed to ensure proper handling of resident personal funds and transmission of required notary statements. |
Report Facts
Residents reviewed for wandering and elopement risk: 5
Residents reviewed for drug regimen: 5
Residents reviewed for respiratory care: 4
Residents reviewed for drug storage and labeling: 8
Residents reviewed for drug regimen free from unnecessary drugs: 2
Residents reviewed for oxygen therapy: 4
Residents reviewed for activities of daily living care: 1
Residents reviewed for medication administration: 5
Inspection Report
Annual Inspection
Deficiencies: 5
Sep 23, 2021
Visit Reason
A Recertification Survey was conducted at St Antoine Residence from 09/20/2021 through 09/23/2021 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified related to advance directives, pressure ulcer treatment, nutrition and hydration, unnecessary drugs, and drug storage and labeling. The facility failed to ensure compliance with regulatory requirements in these areas as evidenced by record reviews, staff interviews, and observations.
Deficiencies (5)
| Description |
|---|
| Failure to ensure residents' advance directives were followed consistently, with inconsistencies between paper medical records and electronic medical records for 6 of 32 residents reviewed. |
| Failure to provide necessary treatment and services to prevent pressure ulcers for 1 of 12 residents reviewed. |
| Failure to maintain acceptable parameters of nutritional status relative to supplements and weight monitoring for 2 of 10 residents reviewed for weight loss. |
| Failure to ensure a resident's drug regimen was free from unnecessary drugs related to inadequate monitoring of medications for 2 of 7 residents reviewed. |
| Failure to store and label drugs and biologicals in accordance with accepted professional principles for 3 of 4 medication carts and 1 of 4 medication rooms observed. |
Report Facts
Residents reviewed for advance directives: 32
Residents reviewed for pressure ulcers: 12
Residents reviewed for weight loss: 10
Residents reviewed for unnecessary drugs: 7
Medication carts and rooms observed: 8
Loading inspection reports...
