St. Agnes Healthcare and Rehab Center

In the surveyor’s words

From the most serious findings on record at St. Agnes Healthcare and Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 26, 2025

  Based on observation, interview, and policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. food was dated after opening; and 2. food was properly sealed and stored. The facility had a census of 95 residents. Findings: On 03/24/2025, a review of the facility's policy titled, Correct Food Storage with a revised date of 12/30/2024, read in part, all foods shall be stored in a manner to ensure First-in - ''First- Out use and all items shall be labeled, dated and sealed. On 03/24/2025 at 9:01 AM, an observation was made of the dry storage area with S1DM (Dietary Manager). […]

• No harm, potential for more than minimal, patternF585May 6, 2026

  Based on interviews and record reviews, the facility failed to identify and correct situations that could possibly result in actual or suspected abuse by failing to immediately report a complaint made by a resident to the Administrator or designee for 1 (#92) resident out of 30 sampled residents. Findings: Review of the facility's policy titled, Grievance, with a last revised date of 11/24/2025, read in part: Grievance or complaint is filed, if staff has received the complaint, he/she is to notify administrator or his designed as soon as possible.Prevention- identify and correct situations that could possibly result in abuse. […]

• No harm, potential for more than minimal, patternF685May 6, 2026

  Based on interview and record review, the facility failed to ensure a resident received an assistive device to maintain and/or improve hearing for 1 (Resident #6) out of 1 resident investigated for communication-sensory.Findings:Review of Resident #6's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included, in part, major depressive disorder, cognitive communication deficit, and anxiety disorder.Review of Resident #6's Quarterly MDS (Minimum Data Set) with an ARD of 02/26/2026, under Section C, revealed she had a BIMS score of 15 which indicated her cognition was intact. […]

• No harm, potential for more than minimal, patternF812May 6, 2026

  Based on observations, interview, and record review, the facility failed to store food in accordance with professional standards for food service and failed to ensure sanitary conditions were maintained in the kitchen by failing to:Appropriately store, label and date frozen food items, and Ensure kitchen staff used good hygienic practices while preparing and serving food to residents.This had the potential to affect 93 residents who consumed foods from the facility's kitchen.Findings:1.On 05/05/2026, a review of the facility's policy titled, Food Storage with a last reviewed date of 11/24/2025, read in part . 14. Frozen Foods .c. All foods should be covered, labeled and dated .All foods will be checked to assure that foods will be consumed by their use by dates or discarded . […]

• No harm, potential for more than minimal, patternF880Mar 26, 2025

  Based on observations, interviews and infection policy review, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to: 1. Appropriately handle and transfer soiled laundry; 2. perform proper hand hygiene; 3. appropriately remove PPE (Personal protective equipment); and 4. sanitize dirty scissors before re-using. Findings: 1. […]