SMP Health - St Aloisius

In the surveyor’s words

From the most serious findings on record at SMP Health - St Aloisius, in the surveyor’s own words.

• Actual harm, isolatedF744Jan 18, 2024

  Based on observation, record review, and resident interviews, the facility failed to provide appropriate dementia care and services for 1 of 1 sampled resident (Resident #65) with a diagnosis of dementia and wandering behaviors. Failure to adequately assess for necessary care and services, and monitor behaviors and implement effective behavior management interventions resulted in a decreased level of psychosocial well-being for Resident #65 as well as other residents affected by the behaviors. Findings include: The facility failed to provide a policy on dementia care. Review of Resident #65's medical record occurred on all days of survey. Diagnoses included dementia, psychotic and mood disturbance, anxiety and restlessness, and agitation. […]

• No harm, potential for more than minimal, widespreadF761Jan 18, 2024

  Based on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure storage of controlled medications for 4 of 4 medication carts (Cart #1 and #2 on Unit A and Cart #1 and #2 on Unit B) and failed to lock 1 of 4 medication carts (Cart #2 on Unit B) observed during medication administration. Failure to store medications securely may result in unauthorized access to medications and/or medication errors. Findings include: Review of the facility policy titled Medication Storage occurred on 01/18/24. This policy, dated August 2021, stated, . 1. General guidelines: a. All drugs and biologicals will be stored in locked compartments. c. During medication pass, medications must be. locked in the medication storage area/cart. […]

• No harm, potential for more than minimal, patternF689Mar 5, 2025

  Based on observation, review of facility policy, and resident and staff interviews, the facility failed to maintain acceptable hot water temperatures for 1 of 2 units (Unit A) observed for water temperature. Failure to ensure acceptable hot water temperatures has the potential for burn injuries to residents, visitors, and staff. Findings include: Review of the facility policy titled Hot Water Temperature Check occurred on 03/04/25. This policy, dated 12/21/11, stated, The domestic hot water must be kept at 110 degrees or less for the safety of our patients, visitors, and employees. The water temperature will be monitored at various locations throughout the facility to ensure that it stays at 110 degrees or less. The temperature in the tank will be monitored by the gauge on the tank. 2. […]

• No harm, potential for more than minimal, patternF880Jan 18, 2024

  Based on observation, record review, review of professional reference, policy review and staff interview, the facility failed to follow standards of infection control for 1 of 12 sampled residents (Resident #28) and 1 supplemental resident (Resident #39) observed during perineal cares and 1 of 1 sampled resident (Resident #65) on transmission-based precautions (TBP). Failure to follow infection control standards during perineal cares and with TBP has the potential to transmit infections to residents, staff, and visitors. Findings include: PERINEAL CARES Review of the policy/procedure titled Perineal cares (Peri-Cares) occurred on 01/18/24. This policy/procedure, dated June 2023, stated, .Washes genital area, moving from front to back. […]

• No harm, potential for more than minimal, patternF812Sep 15, 2021

  Based on observation, facility policy, and staff interview, the facility failed to prepare and serve food under sanitary conditions during 2 of 3 days of meal service observations (09/13/21 and 09/14/21) for Unit B. Failure to follow proper hand hygiene and glove use during meal tray service has the potential to result in foodborne illness to residents. Findings include: Review of the facility policy titled Gloves occurred on 09/14/21. This policy, dated March 2016, stated, . Food preparation shall be done using sanitary precautions . Hands should never touch food in ready-to-eat form . Gloves shall be worn when coming into contact with food during food preparation and serving . […]