St Annes Nursing Center, St Annes Residence Inc

In the surveyor’s words

From the most serious findings on record at St Annes Nursing Center, St Annes Residence Inc, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 13, 2025

  Based on observations, record review, and interviews, the facility's staff neglected to use a mechanical lift to transfer one (Resident #1) of the three sampled residents who required transfers with a mechanical lift. Staff G, a Certified Nursing Assistant, did not use a mechanical lift as ordered to transfer Resident #1 from the bed to the wheelchair. This deficient practice resulted in Resident #1 sustaining multiple fractures to the right lower extremity. Ninety-three residents in the facility required transfer using a mechanical lift.The findings include: Observation on 10/22/2025 at 10:22 AM, revealed Resident #1 receiving a bed bath without any apparent distress. The right leg was completely covered with a bandage wrap dressing. […]

• Actual harm, isolatedF684Nov 13, 2025

  Based on observations, record review and interviews, the facility failed ensure one (Resident #1) out of three sampled residents received higher level of care and treatment in a timely manner, as evidenced by Resident # 1 who has bilateral contracted upper extremities was noted on 10/24/2025 with swelling to her left arm that progressively got worst with swelling and discoloration throughout the inner portion of the left arm and was no longer contracted. Resident #1 was eventually transferred to a local hospital on [DATE] (two days after changes were noted). Hospital Xray of Resident #1's left arm revealed an acute mid humerus spiral fracture with displacement. There were 197 residents residing in the facility at the time of the survey. The findings include. […]

• No harm, potential for more than minimal, patternF656Sep 18, 2025

  Based on observations, record reviews and interviews, the facility failed to create comprehensive, resident-centered individualized care plans for two (Resident #1 and Resident #4) out of two sampled residents as evidenced by their care plans containing generic interventions not tailored to their specific health needs and functional status. The findings include: Review of the facility document_ Subject: Care PlanningEffective: 12/3/2004Revised: 2/22/2006Reviewed: 10/16/2024POLICY:Care, treatment and services are planned to ensure that they are appropriate to the residents' needs. Therefore, it is the policy of this Facility to provide an individualized, interdisciplinary plan of care for all residents that is appropriate to the resident's needs, strengths, limitations and goals. […]

• No harm, potential for more than minimal, patternF803Oct 28, 2022

  Based on observation, record review and interview, facility failed to follow the menu for pureed diets for the evening meal on 10/26/22. There were 79 residents who were served pureed diets in the facility. Findings included: On 10/26/22 at 4:21 PM, observation revealed there was a pan of pureed pasta and a pan of pureed beef held stored on the steam table for the evening meal. Review of the facility Week 6, Day 4 menu indicated 6 ounces (oz). pureed beef and macaroni were to be served for the evening meal for pureed diets (the menu did not indicate that the beef and macaroni was to be served separately). The Director of Food and Nutrition Services stated that they made the pureed beef and pureed macaroni separately, because some residents do not like macaroni. […]

• No harm, potential for more than minimal, patternF812Oct 28, 2022

  Based on observation, record review and interviews, the facility failed to ensure that clean equipment was protected from contamination; clean eating utensils were stored to prevent contamination; Time/Temperature for Safety (TCS) foods were held at proper temperature; and equipment was properly sanitized. This has the potential to affect 179 residents out of 195 residents who consume the facility's food. Findings included: During a follow up visit to the kitchen on 10/26/22 at 4:21 PM, there was a caddy of eating utensils, containing forks and spoons that were stored with their handles down (photographic evidence obtained). Staff would have to touch the lip- or food-contact surface of the eating utensil to remove them from the caddy. […]