Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Saint Anthony Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with chronic pain and other conditions had an active PRN order for hydrocodone-acetaminophen when an LPN removed one of the resident’s narcotic medication cards and its count sheet from the medication cart. Another LPN noticed that one of three narcotic cards and count sheets was missing and confirmed with the pharmacy that three should have been present. Video later showed an LPN taking narcotics and related paperwork from the cart, leaving the building with them, and returning without the medication, and the missing narcotic card was subsequently found at the LPN’s home, constituting misappropriation of the resident’s property.
Missing Physician Order for Oxygen Flow Rate: A resident with multiple diagnoses, including dementia and CKD stage 4, was observed receiving oxygen via NC at 2 L/min, but the clinical record did not contain a physician's order for oxygen that included the indication for use and flow rate setting. The DON stated the oxygen order had not been transcribed, and an RN noted the admitting nurse should have reviewed hospital discharge orders and obtained any needed facility orders.
A staff member at an LTC facility violated a resident's privacy and dignity by photographing and videotaping the resident while asleep and posting the video on social media. The resident, who had severe cognitive deficits, was unaware of the incident. The facility's policy prohibits photographing residents, and the staff member involved was terminated.
A resident with severe cognitive deficits eloped from the facility without staff knowledge, traveling three blocks away before being found. The facility's alarm system was not properly monitored, as a staff member turned off the alarm without checking for missing residents. The resident was unaware of the requirement to notify staff or sign out when leaving.
The facility failed to ensure the wireless call system was functioning properly across all halls, leading to delayed response times. Residents could not confirm if their call requests were received, and staff had issues with accessing notifications on their phones or facility devices. The DON and staff showed a lack of understanding and consistency in using the new system, resulting in residents being given bells as a backup.
A facility failed to include a resident's functional limitation in range of motion in the comprehensive care plan. The resident had contractures of the fingers and was diagnosed with myoclonus, polyosteoarthritis, and right shoulder pain. An OT note indicated arthritis deformities in the hands, but the care plan did not specify affected body parts. The MDS assessment noted limitations in upper extremities, yet the care plan lacked detail. The ADON acknowledged the oversight, contrary to the facility's policy on thorough assessments and updates.
A resident with cognitive and physical impairments was not provided with a dining table adjusted to her needs, resulting in discomfort and difficulty during meals. Despite occupational therapy recommendations and consultations, the resident was seated at a table that was too high, causing her to lean forward and rest her head on the table.
The facility failed to document and monitor a resident's bruising and did not report out-of-range glucometer readings for three residents. A resident's facial bruising was not properly tracked, and two residents with diabetes had blood glucose levels outside the physician's ordered parameters without notification to the physician. The facility did not adhere to its policy on physician notification for significant changes in resident conditions.
A facility failed to ensure proper verification of g-tube placement before medication administration for a resident. An RN used water to check for residual, contrary to the facility's policy, which requires checking stomach contents without water. The RN was unaware of the policy, which also mandates reporting residuals above 100 ml.
Misappropriation of Resident Narcotic Medication by Staff
Penalty
Summary
The facility failed to protect a resident’s belongings by not preventing the theft of narcotic medication prescribed for pain management. A resident with diagnoses including paranoid schizophrenia, hyperlipidemia, dementia, chronic pain, and anxiety had an order for hydrocodone-acetaminophen 7.5-325 mg every 8 hours as needed for pain. An LPN later reported that this resident had three narcotic medication cards and three narcotic count sheets when she left work, but upon her return, only two cards and two count sheets remained. The pharmacy confirmed that the resident should have had three narcotic cards and three corresponding count sheets. Video evidence reviewed by the Administrator showed an LPN removing narcotics from the narcotic drawer of the medication cart, taking a narcotic count sheet, placing both between other papers, and exiting the building to her car with the items. The video further showed the LPN returning to the facility with only two pieces of paper and no medications. The missing narcotic medication card was later found at the LPN’s home according to a police investigation. The facility’s abuse and unusual occurrence policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without the resident’s consent, and the events described met this definition for misappropriation of the resident’s narcotic medication.
Missing Physician Order for Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure a physician's order for oxygen included the indication for use and the equipment setting for the flow rate for Resident 47. During observations on 9/15/25 and 9/16/25, Resident 47 was receiving oxygen via nasal cannula at 2 liters per minute. The clinical record reviewed on 9/11/25 showed diagnoses including diabetes, atrial fibrillation, macular degeneration, anxiety, chronic kidney disease stage 4, psychotic disorder with delusions, and dementia. There was no physician's order in the record for the use of oxygen that included the oxygen flow rate setting. The DON stated on 9/16/25 that the physician's order for oxygen had not been transcribed. RN 2 stated that when Resident 47 was readmitted from the hospital, the admitting nurse should have reviewed the discharge orders, compared them with facility orders, and contacted the facility physician to change or add any new orders. The facility's Medication Administration policy stated medications must be administered in accordance with orders, and the Oxygen Administration policy stated to start the flow of oxygen as ordered by the physician.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold a resident's right to dignity and privacy when a staff member, identified as Staff Member 10, photographed and videotaped a resident, referred to as Resident F, while she was asleep in her wheelchair. The video was subsequently posted online on social media. Resident F, who had a severe cognitive deficit with a Brief Interview for Mental Status (BIMS) score of 3 out of 15, was diagnosed with unspecified dementia, difficulty walking, anemia, and depression. The incident was brought to the attention of the Director of Nursing (DON) through an anonymous tip, and it was confirmed that the video was on Staff Member 10's phone, although the staff member denied posting it online. Interviews with other staff members revealed that they were aware of the facility's policy prohibiting the photographing of residents, even if the resident consented. Despite this, the video was still taken and shared. The facility's policy, titled 'Imaging of Residents, Videotaping, Photographing and Other,' clearly stated that resident photographs are considered healthcare records and should be handled according to regulations governing protected health information. The incident was reported to the nursing board, and the staff member involved was terminated from employment.
Removal Plan
- Staff Member was terminated.
- All staff members were in-serviced/educated on Abuse and Imaging of Residents, Videotaping, Photographing and other policies and procedures.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, resulting in a resident eloping from the facility without staff knowledge. The incident involved a resident with a severe cognitive deficit, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The resident, who had diagnoses including congestive heart failure, vascular dementia, anxiety disorder, and peripheral vascular disease, left the facility with her walker and was found three blocks away. The resident was missing for approximately 20 minutes before being returned to the facility. The elopement occurred when the facility's secondary alarm system, which was supposed to alert staff of any unauthorized exits, was turned off by a staff member without checking for missing residents. The alarm had sounded at 8:07 a.m., but the staff member failed to investigate the cause of the alarm. The resident was last seen by staff at 8:00 a.m. and was later spotted by another staff member on her way to work, who then notified the facility. The resident was unaware of the requirement to notify staff or sign out when leaving the facility. Interviews with staff revealed that the alarm system was not properly monitored, and the staff member responsible for turning off the alarm did not follow the facility's policy and procedure. The facility's policy required residents to sign out and notify their nurse before leaving the building, which the resident did not do. The incident highlighted a lapse in the facility's supervision and monitoring systems, which allowed the resident to leave unnoticed.
Deficiency in Wireless Call System Functionality
Penalty
Summary
The facility failed to ensure that the wireless call system was functioning properly across all five halls reviewed. During a resident council meeting, a resident expressed concerns that the call light notifications, which were supposed to alert staff via their phones, did not provide any visible or audible confirmation to the residents. This led to delays in response times, particularly at night. Observations revealed that the new call system had replaced the old hallway call lights, and staff were expected to receive notifications on their personal or facility phones. However, issues were noted with staff not having their phones turned on or not knowing how to access the system on available devices like iPads. Interviews with staff, including RNs and the DON, highlighted a lack of understanding and consistency in using the new call system. Some staff used personal phones, while others relied on facility phones, which were not always accessible. The DON admitted to not knowing which staff members took phones from the desk, and there was confusion about accessing the call system on iPads due to password issues. The facility's policy required staff to be vigilant and aware of call lights, but the implementation of the new system was inadequate, leading to residents being provided with bells as a backup during system failures.
Deficiency in Comprehensive Care Plan for Resident's Mobility
Penalty
Summary
The facility failed to ensure that a resident's functional limitation in range of motion was included in the comprehensive care plan. During an observation, it was noted that the resident had contractures of the fingers on both hands. The clinical record review revealed diagnoses including myoclonus, polyosteoarthritis, and right shoulder pain. An occupational therapy service note indicated that the resident's hands had minimum to moderate arthritis deformities, which were functional with maximum difficulty. However, the care plan initiated for the resident did not specify the parts of the body affected by arthritis. The Minimum Data Set (MDS) assessment indicated a functional limitation in the resident's upper extremities, including shoulders, elbows, wrists, and hands. Despite this, the care plan only mentioned polyosteoarthritis without detailing the specific areas affected. During an interview, the Assistant Director of Nursing acknowledged the occupational therapist's note about the arthritic changes in the resident's hands. The facility's policy on comprehensive care plans emphasized the need for thorough assessments and updates as resident conditions change, but this was not reflected in the resident's care plan.
Failure to Accommodate Resident's Dining Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident by not providing an appropriately adjusted dining table. Observations on multiple occasions revealed that the resident was seated at a long table with other residents who required assistance to eat, with the table height reaching the level of her chin. This positioning caused the resident to lean forward and rest her head on the table during meals, indicating discomfort and difficulty in maintaining an upright posture while eating. The resident's clinical record indicated diagnoses of mild cognitive impairment, bipolar disorder, mild depression, and adjustment disorder with anxiety. An occupational therapy (OT) order was in place to evaluate and treat the resident, focusing on activities of daily living retraining and therapeutic exercises. Despite a consultation with dining room staff and the resident's daughter to try a lower dining table, the resident continued to be seated at an inappropriate table height. Interviews with staff revealed that the resident had been moved from a lower table to improve her posture, but therapy notes did not support seating her at a table that was too high for her needs.
Failure to Document and Report Resident Conditions
Penalty
Summary
The facility failed to adequately document and monitor a resident's bruising and did not report out-of-range glucometer readings to the physician as ordered for three residents. Resident 124 was observed with significant bruising on the left side of her face, which was not properly documented or monitored. The resident had a history of falls and was on medications that could delay healing, yet the documentation did not consistently track the bruising or provide measurements. The interdisciplinary team and skin assessments failed to include comprehensive details about the bruising, and there was no clear documentation of how or when the bruising occurred. For Resident 12, the facility did not notify the physician of multiple instances where the resident's blood glucose levels were below the ordered threshold of 60. Despite having a care plan that required monitoring and reporting of blood sugar levels, there was no documentation indicating that the physician was informed of these low readings. This oversight occurred over several days, with blood glucose levels recorded as low as 49. Similarly, Resident 15 experienced high blood glucose levels that exceeded the physician's ordered threshold of 400, yet there was no documentation that the physician was notified. The care plan for this resident also required monitoring and reporting of blood sugar levels, but the facility failed to follow through with these orders. The facility's policy on physician notification was not adhered to, as evidenced by the lack of communication regarding significant changes in the residents' conditions.
Failure to Verify G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure proper verification of gastrostomy tube (g-tube) placement prior to medication administration for a resident. During a medication administration observation, a registered nurse (RN) administered 60 milliliters of water into the resident's g-tube and then pulled back on the syringe to check for residual, indicating there was no tube feeding. The RN admitted to not knowing the facility's policy, which requires checking for proper tube placement by assessing stomach contents (residual) without using water. The policy also states that residual volumes should be returned to the stomach and any residual above 100 ml should be reported.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lafayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosewalk Village At Lafayette | 0.4 mi | ★★★★★ | 2 | 0 |
| St Mary Healthcare Center | 0.8 mi | ★★★★★ | 5 | 0 |
| Springs At Lafayette, The | 1 mi | ★★★★★ | 9 | 0 |
| Majestic Care Of Lafayette | 2.5 mi | ★★★★★ | 16 | 0 |
| Westminster Village - West Lafayette | 2.7 mi | ★★★★★ | 6 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.