Saint Ann Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Saint Ann Rehabilitation and Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Mar 18, 2026

  Based on interview and record review, the facility failed to monitor the food's internal temperature to ensure food was safe for consumption on 17 of 30 days reviewed. Findings include: Review on 3/16/26 at approximately 8:30 a.m. of the Main Kitchen with Staff A (Culinary Services Director) revealed that the food temperature logs had missing food temperatures of items served for meals. The following dates and meals did not have food temperatures over the last 30 days:Breakfast: 3/16/26;Lunch: 2/24/26, 2/25/26, 3/5/26;Dinner: 2/16/26, 2/17/26, 2/18/26, 2/19/26, 2/23/26, 2/24/26, 2/25/26, 2/26/26, 2/28/26, 3/2/26, 3/3/26, 3/5/26, 3/6/26, 3/9/26, 3/10/26, 3/11/26.Interview on 3/16/26 at approximately 8:35 a.m. with Staff A confirmed the above findings. […]

• No harm, potential for more than minimal, isolatedF605Mar 18, 2026

  Based on interview and record review, the facility failed to ensure that PRN (as needed) psychotropic medication orders were limited to 14 days for 1 of 5 residents reviewed for unnecessary medications of a final sample of 13 residents. (Resident identifier is #3.)Finding include:Review on 3/18/26 of Resident #3's physician's orders revealed that he/she had orders for PRN Clonazepam without a specified end date on 2/27/26. Interview on 3/18/26 at approximately 1:00 p.m. with Staff C (Director of Clinical Services) confirmed the above findings.Review on 3/18/26 of the facility's policy title Utilization and Documentation of Psychotropic Medications revealed: . […]

• No harm, potential for more than minimal, isolatedF656Mar 18, 2026

  Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 resident in a final sample of 12 residents. (Resident identifier is #4)Findings include:Review on 3/18/26 of Resident #4's diagnosis list revealed a diagnosis of Diabetes. Review of Resident #4's Medication Administration Record revealed that the Resident #4 was on insulin for management of his/her diabetes. Review of Resident #4's current care plan revealed that there were no interventions for diabetes. Interview on 3/18/26 at approximately 11:00 a.m. with Staff C (Director of Clinical Services) confirmed the above findings.

• No harm, potential for more than minimal, isolatedF656Mar 7, 2024

  Based on record review and interview it was determined that the facility failed to develop a Comprehensive Care Plan for 2 of 5 residents reviewed for unnecessary medications in a final sample of 13 residents (Resident Identifiers #9 and #8). Findings include Resident #9 Review on 3/6/24 of Resident #9's medical record revealed that Resident #9 was receiving Effexor (antidepressant medication) ER (extended release). Further review of the medical record revealed that there was not a care plan developed to address the resident's depression or Effexor ER. Interview on 3/7/24 at 2:20 pm with Staff C (Director of Nursing) confirmed the above findings. […]

• No harm, potential for more than minimal, isolatedF658Mar 7, 2024

  Based on observation and interview, it was determined that the facility failed to ensure that medications are administered following professional standards for 1 out of 33 medications observed during medication administration (Resident Identifier #23). Findings include: Standards: Review of Clinical Nursing Skills and Techniques, [NAME] A. [NAME] and [NAME], Mosby, 2018, 9th Edition, revealed the following: page 543 Administering Ophthalmic Medications .7a. Apply clean gloves. Observation on 3/7/24 at approximately 7:30 a.m. of Staff B (Licensed Practical Nurse) during medication administration revealed that Staff B administered eye drops into Resident #23's bilateral eyes without wearing gloves. Interview on 3/7/24 at approximately 7:30 a.m. […]