Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 St. Anthony Healthcare Center during CMS and state inspections, most recent first.
A resident was readmitted with documented deep tissue pressure injuries (DTPI) on both ankles, but initial skin assessments by LPNs failed to identify or document these wounds. The pressure ulcers were not recognized until 15 days later, delaying treatment despite facility policy requiring prompt evaluation and intervention for skin impairments.
Surveyors identified several deficiencies in food service safety, including a grease-laden vent hood without an interim cleaning schedule, pest presence, persistent water leaks causing wet floors, and a dish machine that failed to reach sanitization temperatures due to missing parts and incomplete temperature logs. Additional issues included improper storage of wiping cloths, soiled kitchen equipment, an ice machine with mold-like residue, and a coffee maker lacking required backflow prevention. These failures reflect noncompliance with professional standards for food safety and sanitation.
Numerous gnats and vinegar flies were observed in the kitchen and dish machine room due to ongoing water leaks, standing water, and missing grout lines. Maintenance records and pest control reports documented repeated issues with water accumulation, broken tiles, and unsealed gaps, which provided breeding grounds for pests. Despite these findings, the facility did not resolve the structural and maintenance problems, leading to continued pest activity.
A facility did not consistently enforce separation between two residents during an abuse investigation, despite policy requiring such action. After an incident where one resident was observed with their hand in another's brief, both individuals continued to be in close proximity at the nurse's station, and staff did not always maintain the required distance. The affected resident, who had anxiety disorder, delirium, and insomnia, continued to express concern about the other resident.
Two residents with documented food allergies were repeatedly served meals containing allergens, despite clear indications on meal tickets and family interventions. One resident, allergic to chicken, experienced persistent diarrhea, while another, allergic to tree nuts, was served desserts containing nuts. The facility's dietary staff failed to consistently check meal tickets, and care plans lacked documentation of allergies.
A facility's kitchen hand washing station was found without soap and paper towels during an inspection with the Dietary Manager and Registered Dieticians. The protocol for restocking involved contacting housekeeping, but this was not followed, leading to a deficiency. The facility Administrator stressed the importance of maintaining supplies for proper hand washing, as per the 2017 FDA Food Code.
The facility failed to maintain sanitary conditions in the main floor kitchenette, rehab pantry, and second-floor pantry. Observations included undated and expired food items, ants, soiled equipment, and incomplete refrigerator temperature logs, indicating non-compliance with food safety and sanitation policies.
The facility failed to provide proper incontinence care and clothing for a resident with dementia and heart failure. The resident was often found in wet garments and lacked sufficient clothing, compromising their dignity and quality of life.
A resident with moderately impaired cognition and multiple diagnoses was not offered bedtime snacks on several occasions, despite the facility's policy requiring it. Interviews and record reviews revealed a breakdown in the process for offering and documenting snacks, resulting in nighttime hunger for the resident.
The facility failed to ensure that paper towel dispensers were accessible for a resident with limited mobility and two other residents. Despite multiple reports to management and documentation in Resident Council meeting minutes, no action was taken to resolve the issue, leading to the deficiency.
The facility failed to implement care plan interventions for two residents, resulting in unmet care needs and improper management of pressure sores. Both residents were observed without the required positioning devices, despite having care plans that included such interventions. The DON acknowledged the care plans should be followed until officially changed.
The facility failed to store medication securely, discard expired medication, and label medications properly. A resident had unmonitored pills at their bedside without an assessment for self-administration. Multiple medication carts had open and undated insulin pens, glucose test strips, and eye dropper vials without resident identifiers. Expired Primidone Suspension bottles were also found in a storage room.
Failure to Timely Identify and Treat Pressure Ulcers on Admission
Penalty
Summary
The facility failed to ensure timely identification and treatment of pressure ulcers for a resident who was readmitted following a hospital stay. Upon readmission, the resident's hospital discharge summary documented deep tissue pressure injuries (DTPI) on both ankles. However, the nursing admission assessment and total body skin assessment completed by two LPNs did not identify or document any ankle or foot wounds, and both assessments indicated no new wounds or skin conditions. Interviews with the LPNs revealed they could not recall specifically inspecting the resident's feet or ankles during the assessments, though it was acknowledged that a full body inspection was expected. The pressure ulcers were not identified by facility staff until 15 days after the resident's readmission, when a change in condition note prompted a wound care physician consult. The subsequent wound care assessment confirmed the presence of deep tissue injuries on both feet, which were present on admission. Facility policy required a baseline total body skin evaluation upon admission and prompt documentation and intervention for any skin impairments, but these steps were not followed, resulting in a delay in the identification and treatment of the resident's pressure ulcers.
Multiple Food Service Sanitation and Equipment Failures
Penalty
Summary
Surveyors observed multiple failures in food service safety and sanitation within the facility's kitchen and kitchenette areas. The vent hood in the kitchen had a heavy buildup of grease, with documentation showing it had not been cleaned since 3/26/25, and no interim cleaning schedule was in place. Gnats were present in the dish machine room and near the three-compartment sink, and the floor in the dish machine room was very wet with standing water and pooling in several areas due to continuous leaks from the recessed drain well and the sink basin drain pipe. These conditions were not in accordance with professional standards for cleanliness and pest control. The high temperature dish machine failed to reach the required sanitization temperature, as indicated by both temperature indicator strips and a dishwasher plate thermometer, which recorded maximum surface temperatures below the required 160 degrees Fahrenheit. The dish machine was also missing essential internal curtains, and temperature logs were not maintained daily as required. Additionally, a wet wiping cloth was left on a food preparation counter without a sanitizer bucket, and the first-floor kitchenette microwave was soiled, with the ice machine showing dust and a pinkish-orange slime along the ice chute. The ice machine drain line was improperly installed, extending too far into the floor drain. Further deficiencies included the absence of backflow prevention on the water supply line to a coffee maker in the second-floor kitchenette, contrary to manufacturer and code requirements. These observations collectively demonstrate a failure to maintain food service equipment and areas in accordance with professional standards, increasing the risk of contamination and foodborne illness for all residents consuming food from the kitchen.
Failure to Eliminate Harborage Conditions for Effective Pest Control
Penalty
Summary
The facility failed to eliminate harborage conditions necessary to maintain an effective pest control program, as evidenced by the presence of numerous gnats in the dish machine room and near the 3 compartment sink in the kitchen. Observations revealed a continuous leak of water onto the floor from the recessed drain well and the drain pipe for the sink basin on the soiled side of the dish machine, resulting in a very wet floor with standing water between floor tiles and pooled water in the corner behind the door. These conditions were confirmed during interviews with the Maintenance Director, who acknowledged the need for regrouting and pipe repairs. Review of pest control service reports over several months documented ongoing issues, including repeated sightings of vinegar flies in the dish area, standing water, missing grout lines, and broken tiles. The reports consistently noted that these structural and maintenance deficiencies provided breeding grounds for flies, with recommendations to repair leaks, replace broken tiles, and seal gaps to prevent further pest activity. Despite these documented concerns, the facility did not address the underlying causes, resulting in persistent pest activity in the kitchen and dishwashing areas.
Failure to Consistently Enforce Resident Separation During Abuse Investigation
Penalty
Summary
The facility failed to consistently implement effective separation measures to prevent further abuse during an ongoing abuse investigation involving two residents. After an incident where one resident was observed with their hand in another resident's brief, staff separated the residents and notified appropriate personnel. However, subsequent observations revealed that both residents continued to be in close proximity at the nurse's station, with one resident talking to the other and a staff member present but not actively monitoring their interaction. Interviews with staff indicated that instructions were given to keep the residents an arm's length apart, but this was not consistently enforced, as evidenced by the residents being observed near each other and interacting. The resident who was the subject of the abuse investigation had diagnoses including anxiety disorder, delirium, and insomnia, and required staff assistance with mobility and transfers. Despite the facility's policy requiring separation of residents involved in suspected abuse, the alleged perpetrator continued to have access to the other resident during the investigation period. Staff interviews confirmed that the separation protocol was not always maintained, and the resident continued to express concern about the other individual when they were in proximity.
Failure to Accommodate Resident Food Allergies
Penalty
Summary
The facility failed to provide food that accommodated the allergies of two residents, R703 and R706, as observed during a survey. R703, who has an allergy to chicken, was repeatedly served chicken or chicken-based meals despite clear indications on their meal ticket and family interventions. The resident experienced persistent diarrhea as a reaction to chicken and expressed frustration over the facility's failure to acknowledge their dietary needs, despite having been at the facility for over two years. The facility's dietary manager acknowledged awareness of the allergy but failed to ensure consistent provision of alternate meals. R706, who is allergic to tree nuts, was served walnuts in a holiday dessert, which they did not consume but expressed anger and concern over the repeated exposure to allergens. The resident reported that their meal tickets clearly indicated a tree nut allergy, yet they continued to receive desserts containing nuts. The resident also received food items they disliked, such as pork and bananas, despite having communicated these preferences to the kitchen manager. Both residents' care plans lacked documentation of their allergies, and the facility's dietary staff failed to consistently check meal tickets for allergies and preferences. The facility's policies on diet orders and food preferences were not effectively implemented, leading to repeated instances of residents being served food they were allergic to. The facility's staff, including the Certified Dietary Manager and Registered Dietician, acknowledged the issues but did not take adequate steps to prevent recurrence.
Kitchen Hand Washing Station Lacks Soap and Towels
Penalty
Summary
The facility failed to ensure that the kitchen hand washing station was adequately supplied with soap and paper towels, as observed during a tour of the kitchen. The inspection, conducted with the facility's Dietary Manager (DM) and two Registered Dieticians (RD B and RD C), revealed that both the hand soap dispenser and the paper towel dispenser were empty. Additionally, there was no secondary or backup supply of soap or paper towels readily available for use by the kitchen staff. The facility's Dietary Manager reported that the protocol for restocking the hand washing station involved kitchen staff contacting housekeeping staff to refill supplies. However, this procedure was not followed, resulting in the deficiency. The facility Administrator emphasized the expectation that the hand washing station should not be left without soap or paper towels, highlighting the importance of hand washing over relying on hand sanitizer. The deficiency was in violation of the 2017 FDA Food Code, which mandates that each handwashing sink must be provided with a supply of hand cleaning soap and individual, disposable towels.
Sanitation Issues in Kitchenette and Pantries
Penalty
Summary
The facility failed to maintain sanitary conditions in multiple areas, including the main floor kitchenette, the rehab pantry, and the second-floor pantry. During an initial dietary tour, several issues were observed: in the rehab pantry, there were undated and expired food items in the resident refrigerator, and ants were found around the floor drain next to the ice machine. The Dietary Manager (DM) acknowledged these issues and stated that nursing staff is responsible for dating resident food items and that maintenance would be informed about the ant problem. In the main floor kitchenette, the microwave was heavily soiled with dried food debris, and the floor was dirty with sticky spills, food debris, and trash. Additionally, the resident refrigerator contained undated food items, and the refrigerator temperature log was incomplete for April and missing for May. The DM confirmed that the refrigerator temperature should be logged daily. In the second-floor pantry, the resident refrigerator contained undated and unidentified food items emitting a rotten odor, and the interior was soiled with food debris and sticky spills. The facility's policy on food from outside sources, revised in November 2021, requires all food brought in to be placed in a sealed container, labeled with the content, the resident's name, the date the food was received, and an expiration date of three days after the food was brought in. These observations indicate a failure to adhere to the facility's food safety and sanitation policies, potentially affecting all residents consuming food from these areas.
Failure to Provide Adequate Incontinence Care and Clothing
Penalty
Summary
The facility failed to ensure proper incontinence care and clothing availability for a resident (R119). On multiple occasions, R119 was observed in a hospital gown and brief, which were often wet and not promptly changed. Despite R119 expressing a preference for wearing clothes, the resident was frequently found without adequate clothing. The CNA responsible for R119's care did not consistently check or change the resident's incontinence pad and gown, leading to the resident remaining in wet garments for extended periods. Additionally, the facility did not ensure that R119 had sufficient clothing, as evidenced by the limited items found in the resident's room and the delayed response in obtaining more clothes from the laundry or guardian approval for new clothes. R119, who has been a resident since December 2023, has diagnoses including dementia and heart failure and requires assistance with daily living activities. The care plan for R119 includes encouraging the resident to choose their clothing and assisting with self-care. However, the facility's failure to provide adequate clothing and timely incontinence care compromised the resident's dignity and quality of life. The facility's policies on resident rights and CNA practices were not adhered to, resulting in the resident's needs not being met consistently.
Failure to Offer Bedtime Snacks to Resident
Penalty
Summary
The facility failed to ensure that a resident (R125) was offered a bedtime snack, resulting in nighttime hunger. During an initial tour, R125 expressed dissatisfaction with the food and snacks provided, stating they only recently learned about the availability of snacks and had never been offered a bedtime snack. A review of R125's electronic medical record (EMR) confirmed that bedtime snacks were not offered on multiple dates. R125, who has diagnoses including Metabolic encephalopathy and Generalized anxiety disorder, was admitted with moderately impaired cognition, further complicating their ability to advocate for themselves. Interviews with the Activity Director (AD) and the Administrator (NHA) revealed a breakdown in the process for offering and documenting bedtime snacks. The AD indicated that evening activity aides are responsible for offering and documenting snacks, but the CNAs are supposed to transfer this information to the EMR. The NHA confirmed that the facility's policy mandates offering bedtime snacks to all residents without dietary or medical restrictions. However, the documentation review and interviews indicated that this policy was not consistently followed, leading to the deficiency.
Inaccessible Paper Towel Dispensers
Penalty
Summary
The facility failed to ensure that paper towel dispensers were accessible for a resident and two anonymous group residents. One resident, who had diagnoses including Osteoarthritis, Pain in the Right Shoulder, Pain in the Left Elbow, and Left Tibia/Fibula Fractures, reported that the paper towel dispensers in their bathroom and the first-floor dining room were too high and they couldn't reach them. This resident, who could not stand independently and had limited shoulder range of motion, expressed their concern to management but received no resolution. During a Resident Council meeting, two anonymous group members also reported being unable to reach the paper towel dispensers and stated they had communicated this issue to the facility's Maintenance Director and Administrator multiple times without any response or resolution. The issue was documented in the Resident Council meeting minutes for April 2024 as a maintenance department-related concern. The Resident Council President confirmed that the issue had been brought up months ago when there was a different Maintenance Director. The facility's Administrator acknowledged that the expectation was for paper towel dispensers to be accessible to all residents. The facility's policy on guest/resident rights and facility responsibilities, dated April 19, 2022, included a section on reasonable accommodation, stating that residents have the right to reside and receive services with reasonable accommodation of their needs and preferences. The policy also emphasized that the physical layout of the facility should maximize resident independence and not pose a safety risk. Despite these policies, the facility did not take appropriate action to address the accessibility issue with the paper towel dispensers, leading to the deficiency noted in the report.
Failure to Implement Care Plan Interventions
Penalty
Summary
The facility failed to ensure care planned interventions were implemented for two residents, resulting in unmet care needs. Resident 74 was observed multiple times in a supine position without the use of a wedge or other device to offload pressure from their buttocks, despite having a care plan that included such interventions. The resident reported significant pain and had a wound on their buttocks that was not being properly managed. The Director of Nursing (DON) acknowledged that the resident had a history of refusing the wedge but noted that the care plan should still be followed until officially changed. Resident 102 was also observed in a supine position in a recliner without the use of a wedge or similar device, despite having a care plan that included these interventions. The resident was seen in the same position for extended periods and reported discomfort. The DON confirmed that the resident had refused the wedge in the past but acknowledged that the care plan should be adhered to until it is officially updated. The resident had a documented sacral pressure ulcer that was not being adequately managed according to the care plan. The facility's policies on care planning and skin management were not followed, leading to deficiencies in the care of these residents. The care plans for both residents included specific interventions to prevent pressure sores and manage pain, but these interventions were not consistently implemented. The DON admitted that the facility had challenges with wound care in the past but believed they were doing a good job, despite the observed deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store medication in a safe and secure manner for one resident, failed to discard expired medication in one of two medication storage rooms, and failed to label medications in three of five medication treatment carts reviewed. Specifically, four pills were observed in a small plastic cup on a table next to a resident's bed, and the resident confirmed that they did not self-administer their medications. The resident's electronic medical record (EMR) lacked documentation indicating that the resident was assessed and deemed appropriate to self-administer their medications. The Director of Nursing (DON) confirmed that medications should only be left unmonitored at a resident's bedside if the resident has been assessed and deemed appropriate to self-administer their medications. Additionally, observations of medication carts revealed multiple instances of open and undated insulin pens, glucose test strips, and eye dropper vials without resident identifiers. Furthermore, six bottles of Primidone Suspension with expired use-by dates were found in a medication storage room. The facility's policy on the storage and expiration dating of medications and biologicals was reviewed, indicating that expired or deteriorated medications should be stored separately until destroyed or returned to the pharmacy. However, this policy was not followed, leading to the deficiencies observed.
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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 Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Point Nsg Phy Rehab Ctr Of Madison Heights | 0.9 mi | — | 0 | 0 |
| Pomeroy Living Sterling Skilled Rehabilitation | 1.6 mi | ★★★★★ | 1 | 0 |
| Windemere Park Health And Rehabilitation Center | 2 mi | ★★★★★ | 2 | 0 |
| Harmony Village Of Warren | 2.9 mi | ★★★★★ | 1 | 0 |
| The Villa At City Center | 2.9 mi | ★★★★★ | 7 | 0 |
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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.