St. Anne's Salvatorian Campus

In the surveyor’s words

From the most serious findings on record at St. Anne's Salvatorian Campus, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 17, 2023

  Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (R20) was free from abuse. The facility did not ensure R20 was free from an alleged sexual abuse by a visitor. On 7/21/23, Certified Nursing Assistant (CNA-D), observed visitor (I) inappropriately touching R20 with his hand between R20's legs and on R20's vagina. CNA-D did not immediately report this allegation of abuse. Visitor (I) remained in the facility and was later observed in R20's room with the lights off and with his hand under the covers while R20 was in bed. CNA-D did not report the observations of alleged sexual abuse until 7/24/23, allowing visitor (I) to visit R20 one more time (on 7/23/23) before being reported. […]

• Immediate jeopardy, isolatedF609Aug 17, 2023

  Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 (R20) of 1 residents reviewed where an allegation of abuse was not reported as a suspicion of a crime to law enforcement, and where 2 (R20 and R30) of 3 residents reviewed for allegations of abuse was not reported immediately, but not later than 2 hours to the state agency, and steps were not immediately taken to prevent further potential abuse. On 7/21/23, Certified Nursing Assistant (CNA-D), observed a visitor (Visitor I) inappropriately touching R20, with his hand between R20's legs and on R20's vagina. […]

• Immediate jeopardy, isolatedF686Aug 17, 2023

  Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 5 (R137, R31, R88, R21, & R87) of 5 Residents reviewed for pressure injuries. * On 1/24/2023, R137 developed a Stage 3 pressure injury to the coccyx and a Stage 3 pressure injury to the right ear A treatment was not started until 3 days later on 1/27/23. The pressure injury resolved on 2/7/23. On 1/31/2023 the Stage 3 pressure injury to the coccyx became Unstageable and no treatment was implemented at that time. […]

• Actual harm, isolatedF686Mar 26, 2026

  Based on observation, interview, and record review, the facility did not ensure residents at risk of pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries for 1 (R34) of 1 resident reviewed. *R34 was admitted to the facility 2/23/26 without any pressure injuries, and the facility assessed R34 to be at high risk for the development of pressure injuries. R34 developed two avoidable facility acquired, unstageable pressure injuries to the right and left legs on 3/22/26. […]

• Actual harm, isolatedF689Jan 7, 2026

  Based on interviews and record review the facility did not ensure that residents' environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 (R2) residents reviewed for accidents. R2 sustained an avoidable fall from bed during cares. R2 was assessed as being dependent for bed mobility as assessed and documented on their significant change and most recent quarterly Minimum Data Set. An assessment code of 01 dependent indicates the need for two staff assistance. R2 was also assessed by therapy as being dependent on staff for bed mobility with the number of staff assistance needed not specified. […]