Sainte Anne Extended Healthcare

In the surveyor’s words

From the most serious findings on record at Sainte Anne Extended Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 11, 2021

  Based on observation, interview and document review, the facility failed to identify an increased risk of elopement for 1 of 3 (R1) residents equipped with security safety alarm devices (aka. wander guard) who exited the building through unalarmed exit doors. The facility's failure resulted in an Immediate Jeopardy (IJ) when R1 exited the building unnoticed through unsecured doors. This practice had the potential to affect other residents who had wander guard system devices in place at the time of survey for 2 of 2 residents (R3 and R4). The IJ began on 6/5/21, at 08:41 a.m. when R1 exited the 4th floor and into a stairwell through an unsecured exit door to the main floor and walked around the building outdoors to a nearby church with out being noticed. […]

• Actual harm, isolatedF689Nov 4, 2024

  Based on interview and document review, the facility failed to follow a care planned intervention to prevent or reduce the risk of falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm when R1 fell and sustained a right fibular fracture which required an emergency room (ER) visit. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severely impaired cognition and diagnoses of dementia, fracture of upper and lower end of right fibula, anxiety disorder and depression. Further identified R1 required 2-person extensive assist with bed mobility, transfers, and toileting. […]

• Actual harm, isolatedF684Dec 14, 2023

  Based on observation, interview and document review the facility failed to provide appropriate care in a timely manner to prevent a decline in condition for 1 of 1 residents (R32) when R32 continued to experience prolonged nausea and decline lasting more than three weeks causing harm. As a result, R32 was sent to the emergency department (ED) and admitted to the intensive care unit (ICU) after the facility failed to ensure the provider was fully appraised of R32's signs and symptoms. Findings include: R32's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R32 was admitted to the facility on [DATE] after a right knee fracture, had moderate cognitive impairment and was dependent on staff for toileting, bathing, personal hygiene, transfers, and locomotion. […]

• No harm, potential for more than minimal, patternF550Feb 13, 2025

  Based on observation, interview, and record review the facility failed to ensure a dignified dining experience for residents who required assistance with eating. This had the potential to affect all residents in the facility who were dependent on staff for their intake of nutrition. Findings include: During an observation of the main floor dining room on 2/10/25 at 5:08 p.m., nursing staff were standing while feeding residents. The staff would move from table to table to assist different residents and were found to not have engaged with the residents during the meal. […]

• No harm, potential for more than minimal, patternF761Feb 13, 2025

  Based on observation, interview, and document review, the facility failed to maintain separately locked, permanently affixed compartments for storage of controlled drugs for 4 of 4 observed medication storage areas during a facility wide remodel. Findings include: During an observation and interview on 2/13/25 at 9:08 a.m., licensed practical nurse (LPN)-B identified the current refrigerator used to store medication on the 2nd floor was locked. The locked refrigerator was not affixed to any permanent surface and was in a temporary nurse's station in the open while the facility was in the middle of a remodel. LPN-B identified the medications in the refrigerator contained flu shot, insulin pens, tuberculin, and Ativan (antianxiety). […]