St. Anthony Healthcare and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Feb 15, 2022

  Based on record review, observation, and interview, the following was identified: 1. A resident on the dementia unit (R #1) known to have prior medication hoarding behaviors was found to have a total of 29 medications inside her purse, including [MEDICATION(S)] (antipsychotic), Buproprion HCL ([MEDICATION(S)]) ER (extended release) (antianxiety), [MEDICATION(S)] (antianginal), [MEDICATION(S)] (blood pressure) and [MEDICATION(S)] (diuretic) [3 days of medication], and was in possession of Gabapentine (nerve pain) medication in a cup not ordered for this resident by physician. The resident had in her purse 3 days of medications not taken, including blood pressure medication. On 01/09/22, the resident experienced a hypertensive episode and was transferred to the hospital for higher care. 2. […]

• Immediate jeopardy, patternF600Oct 20, 2021

  Based on record review and interview, the following was identified: 1. A resident to resident altercation between R #7 and R #9 resulted in R #7 pushing R #9 resulting in a [CONDITION(S)]. 2. A resident (R #7) with known behaviors (hitting and pushing) pushed another resident (R #9) to the floor causing a hip fracture, this same resident (R #7) exhibited continued behaviors after medication adjustments and monitoring interventions were placed in care plan. No new interventions were implemented after 3 additional instances of abusive behaviors towards other dementia residents, on 08/09/21 of verbal abuse towards R #15, 09/07/21 throwing of roommate's items around room, and 10/12/21 striking resident R #15. 3. […]

• Immediate jeopardy, patternF741Oct 20, 2021

  Based on record review and interview, the following was identified: 1. A resident to resident altercation between R #7 and R #9 resulted in R #7 pushing R #9 resulting in a [CONDITION(S)]. 2. A resident (R #7) with known behaviors (hitting and pushing) pushed another resident (R #9) to the floor causing a hip fracture, this same resident (R #7) exhibited continued behaviors after medication adjustments and monitoring interventions were placed in care plan. No new interventions were implemented after 3 additional instances of abusive behaviors towards other dementia residents, on 08/09/21 of verbal abuse towards R #15, 09/07/21 throwing of roommate's items around room, and 10/12/21 striking resident R #15 3. […]

• Immediate jeopardy, isolatedF689Jul 26, 2024

  Based on observation, interview, record review, and facility policy review, the facility failed to: 1. Ensure the environment was free of accident hazards when water temperatures were not maintained at a safe temperature level for six of 20 residents (Resident (R) 31, R23, R43, R22, R18, and R41) residing on the dementia care unit. 0n 07/19/24, water temperatures at the hand washing sinks on the dementia care unit were recorded to be 123.4 degrees Fahrenheit (F). Water temperatures were adjusted but no monitoring occurred. On 07/24/24, water temperatures in two resident bathrooms were noted to be 122 degrees F and 125 degrees F. The water temperatures were not adjusted after water was measured to be in excess of 120-degree F. […]

• Immediate jeopardy, isolatedF689Jan 4, 2023

  Based on record review, observations, and interviews, the facility failed to prevent accidents by not ensuring 1 (R #1) of 14 (R #'s 1-14) residents reviewed for therapeutic diets, were receiving the proper therapeutic diet (diet consistency to meet resident ability to consume it) and failed to implement corrective measures to ensure residents receive their order therapeutic diets following the choking incident. This failure likely resulted in R #1 to have a choking episode and loss of consciousness (ability to be aware) requiring medical intervention. The findings are: A. […]