St Anthony Senior Services

In the surveyor’s words

From the most serious findings on record at St Anthony Senior Services, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jan 25, 2024

  Based on observations, clinical record review, resident and staff interviews, and facility policy review, the facility failed to protect residents from possible accidents and injuries. An electric space heater was used to provide supplemental heat to 3 rooms without out monitoring or supervision. Two rooms were in the Memory Care Unit with residents who had Brief Interview for Mental Status (BIMS) scores of 3 and 5 out of 15, indicating severe cognitive impairment. One resident was ambulatory and at risk for unsafe wandering per their Care Plan. Space heaters were provided on the weekend of 1/13/24 and removed 1/22/24 for 4 of 74 residents reviewed (Resident #1, #20, #30, and #173). […]

• Actual harm, isolatedF600Apr 1, 2026

  Based on observations, clinical record review, facility investigative file review, staff interviews and facility policy review the facility failed to protect the resident's right to be free from physical abuse by a facility staff member for 1 of 3 residents (Resident #1). The facility reported a census of 73 residents. Findings include:According to the quarterly Minimum Data Set (MDS) assessment with a reference date of 3/17/2026, Resident #1 scored 0 on the Brief Interview of Mental Status (BIMS). A score of 0 suggested severe cognitive impairment. The MDS documented he had impairments to his bilateral upper and lower extremities and utilized a wheelchair. Resident #1 was dependent on staff for toileting hygiene, upper and lower body dressing, mobility, and toileting transfers. […]

• Actual harm, isolatedF689Oct 15, 2025

  Based on clinical record reviews, hospital record review, staff interviews and policy review, the facility failed to provide adequate nursing supervision to prevent accident and injuries for 1 of 3 residents reviewed (Resident #1) for falls. The facility failed to implement effective interventions and follow the care plan to prevent falls. Resident #1 was at risk for falls and had a history of repeated falls with trends. Resident #1 had eight falls from January 2025 to August 2025. On 6/1/25 Resident #1 had a fall in her room after attempting to self transfer from her wheelchair to her recliner, resulting in her hitting her head and sustaining a laceration to her forehead requiring an emergency room (ER) visit and 8 staples. […]

• No harm, potential for more than minimal, patternF812Jan 23, 2025

  Based on observation, staff interviews and policy review, the facility failed to ensure open items were dated, covered and labeled. The facility further failed to ensure staff used proper hand hygiene practices during lunch service while serving food. The facility reported a census of 76 residents. Findings include: 1. Observation 1/21/25 at 10:00 AM in the main kitchen with Staff I, Food and Service Director, present revealed the following: a. Two open undated bags of pasta b. Open undated bag of graham cracker crumbs During an interview 1/21/25 at 10:20 AM, Staff I stated an expectation the food is dated, labeled and sealed after it is opened. Staff I stated an intention to label and date these food items and return them to the pantry. […]

• No harm, potential for more than minimal, patternF689Dec 12, 2023

  Based on observations, clinical record review, staff interviews, and facility policy the facility failed to provide adequate supervision to ensure residents remained safe from another resident for 3 of 5 residents reviewed (Residents #3, #4 and #5). In addition, the facility failed to provide 1 of 5 residents reviewed with enough supervision to prevent him for attempting to hurt other residents (Resident #6). Resident #6 had physical altercations on 11/18/23 with Resident #4, 11/21/23 with Resident #5, and 11/24/23 with Resident #3. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified him with short- and long-term memory impairments and severely impaired for decision making abilities. […]