St Anthony's NSG & Rehab CTR

In the surveyor’s words

From the most serious findings on record at St Anthony's NSG & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, widespreadF678Jan 27, 2024

  This failure resulted in two deficient practice statements. A. Based on interview and record review, the facility failed to have adequate qualified staff to conduct basic life support/cardiopulmonary resuscitation (BLS/CPR) per their job descriptions, failed to provide BLS/CPR for 1 resident (R6) of 9 residents reviewed for CPR in the sample of 22. B. Based on document review and interview, it was determined the facility failed to ensure emergency equipment was available for resident care. This failure has the potential to affect all residents with a current census of 87 residents. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on [DATE]. The Immediate Jeopardy was identified on [DATE] and the administrator was notified on [DATE]. […]

• Immediate jeopardy, widespreadF725Aug 18, 2022

  Based on interview, observation and record review, the facility failed to ensure that sufficient staff was available to meet the needs of residents. Between [DATE] - [DATE], the facility had multiple days of not meeting their minimum staffing requirements. On [DATE], the facility did not meet their minimum staffing requirements, R1 was put to bed around 8:30 PM, did not get checked on by staff for nearly 12 hours, and was subsequently found deceased in bed the following morning. R1 was found in a state of rigor mortis (stiffening of the joints and muscles of a body after death) on discovery. These failures have the potential to affect all 76 residents residing in the facility. […]

• Immediate jeopardy, widespreadF812Oct 28, 2021

  Based on observation, interview, and record review, the facility failed to reheat food to the appropriate temperature to kill pathogenic microorganisms that may cause foodborne illness, maintain safe food temperatures of food being held on the steam table, cool food in a manner that prevents the growth of pathogenic microorganisms, and ensure the prevention of potential foodborne pathogens through the monitoring of the temperatures of the resident dishwasher. As a result of this failure, a serious adverse outcome is likely to occur in an outbreak of foodborne pathogen illness. […]

• Immediate jeopardy, isolatedF689May 7, 2024

  Based on interview and record review the facility failed to accurately assess a resident at risk for elopement and failed to implement interventions for a resident at risk for elopement resulting in R1 eloping form the facility unsupervised on 4/19/24 at approximately 7:00 PM. R1 did not return to the facility until approximately 1:00 PM on 4/20/24. This applies to one of three residents (R1) reviewed for elopement in the sample of eight. The Immediate Jeopardy began on 4/10/24 when R1 did not return from a leave from the facility with a friend until the city public bus system brought R1 back to the facility between 8:00 PM and 8:30 PM. […]

• Immediate jeopardy, isolatedF695Jan 27, 2024

  A. Based on observation, interview and record review, the facility failed to ensure tracheostomy supplies were available for tracheostomy care and emergency treatment, failed to obtain physician orders for tracheostomy care, failed to have a tracheostomy policy and procedure, failed to ensure staff were qualified and/or competent to perform tracheostomy care and order appropriate tracheostomy supplies for 3 of 3 residents (R3, R6, R7) admitted with tracheostomies int the sample of 22. These failures resulted in an Immediate Jeopardy: The Immediate Jeopardy started on [DATE]. The administrator was notified of the Immediate Jeopardy on [DATE]. […]