Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Anthony Health & Rehabilitation during CMS and state inspections, most recent first.
Failure to Use PPE During Soiled Laundry Sorting: During a laundry room observation, no PPE was seen in the dirty linen sorting area. The HS confirmed staff only wore gloves and did not use the required gown or goggles when sorting soiled laundry, stating this had been the routine since they started in the laundry room. The administrator stated the expectation was full PPE, including gown, gloves, and goggles, and also stated the facility did not have a laundry policy.
A resident with a urinary catheter was observed ambulating with an uncovered catheter bag hanging from a walker while passing staff and residents in common areas. OT-A said she forgot to move the privacy bag, and the resident stated a preference for the catheter bag to be covered in public areas. RN-A stated catheter bags were to be covered and called it a dignity issue.
A resident with severe cognitive impairment and multiple chronic conditions had a Morphine order that did not match the pharmacy card in the EMAR. The EMAR listed a 15 mg tablet with a 2.5 mg sublingual dose every 3 hours, while the pharmacy card showed a 2.5 mg solutab every 6 hours; RN-A acknowledged the mismatch, did not use the dose-change sticker, and continued using the card because the dose matched. The DON and pharmacist confirmed the transcription error and that the orders and cards were expected to match.
A resident with severe cognitive impairment and diagnoses including HTN, renal insufficiency, diabetes, dementia, and stroke had orders for three BP meds. A monthly pharmacy review requested HOLD parameters for SBP 100 or less, and the provider signed off on the change, but the parameters were never entered into the chart or medication orders. The RNC, pharmacist, and DON all confirmed the orders were not updated as directed.
Binding arbitration agreements were not clearly communicated in a form and manner understood by a resident before signing. A resident with intact cognition, dementia, moderate vision impairment, and a need for help reading written materials signed an undated arbitration agreement, but later stated he would not have signed it and could not read or write. Staff described limited training and inconsistent explanations of the agreement, and the facility document lacked evidence that the resident or representative understood the terms or that the agreement was explained in a language they understood.
Failure to offer and provide pneumococcal vaccination to two residents. Two residents with multiple chronic conditions, including DM and HTN, were identified as due for the next pneumonia vaccine, but the record lacked evidence PCV20 was administered. One resident had signed consent for PCV20, while the other’s consent form stated the vaccine had not been offered. The RNC confirmed both residents were missed and stated the expectation was for vaccines to be offered and provided upon admission.
A resident with severe cognitive impairment experienced two falls, after which interventions such as PRN medications, frequent rounding, and hospice review were implemented but not added to the care plan. Staff interviews confirmed reliance on the care plan for fall interventions and acknowledged that required updates were not made, contrary to facility policy.
The facility did not maintain effective QAPI oversight, resulting in repeat deficiencies related to quality of care, care planning, and self-administration of medications. Two residents did not receive medications according to physician orders, a resident with increased care needs lacked an updated care plan, and another resident was not properly assessed for self-administration of medications. QAPI meeting minutes lacked ongoing tracking of these issues, and the facility had not been monitoring compliance with previous surveys.
A resident with multiple chronic conditions and intact cognition was found with a nebulizer and medication at bedside without a completed self-administration of medications (SAM) assessment or order. Nursing staff confirmed the absence of required documentation and care plan updates, despite facility policy mandating interdisciplinary assessment and care plan inclusion before permitting self-administration.
A resident with terminal lung cancer and other chronic conditions experienced a significant decline, becoming dependent on staff for all personal care needs. Despite clear observations and staff acknowledgment of the resident's increased dependency, the care plan and Kardex were not updated to reflect these changes, contrary to facility policy requiring care plan revisions after a change in status.
A resident with cognitive and mobility impairments who was dependent on staff for ADLs did not receive necessary nail and grooming care. The resident was observed with long, irregular fingernails and unshaven facial hair, and reported not receiving an electric razor after requesting one. Staff interviews confirmed that nail care and grooming were not performed as required, despite facility policy mandating assistance for residents unable to complete these tasks.
Two residents received medications in a manner inconsistent with current physician orders and parameters, including incorrect dosages, frequencies, and lack of required monitoring such as blood pressure and MAP. Staff were unfamiliar with certain medication parameters, and discrepancies between signed orders and the MAR were not identified or addressed, resulting in administration errors.
A resident with significant mobility limitations and multiple diagnoses did not receive range of motion (ROM) exercises as needed. The care plan lacked specific ROM interventions, and no therapy referral was made after the family requested ROM therapy for stiffness. Staff interviews and facility policy confirmed that a referral and care plan update should have occurred, but these actions were not taken.
A consulting pharmacist did not identify or report irregularities in medication administration parameters for two residents. One resident received metoprolol without required blood pressure checks, and another received hydralazine and carvedilol without proper monitoring of mean arterial pressure (MAP) as ordered. The pharmacist's monthly reviews over six months failed to detect these issues, and staff interviews confirmed that MAP is not a standard parameter in this setting.
A facility failed to properly assess a resident's capacity to consent to sexual activity, leading to an inadequate investigation of an alleged sexual abuse incident. Despite the resident's severe cognitive impairment, the facility relied on verbal consent and the absence of distress, without a comprehensive assessment. The lack of a specific policy on capacity to consent contributed to the deficiency.
A facility failed to assess a resident's capacity to consent to sexual activity, leading to a deficiency. Two residents, one with severe cognitive impairment, were found being intimate. The resident's care plan acknowledged her impairment but noted consent to a relationship. A psychiatry assessment later found she lacked capacity to consent, but this was not done before the incident. The facility's decision to allow the relationship was based on verbal consent and lack of distress, without a thorough assessment.
The facility failed to notify the Ombudsman for LTC of hospital transfers for three residents, despite their significant medical conditions. The facility's policy only required notification for discharges, not transfers, and the social services director was unaware of the need to notify the Ombudsman for hospital transfers.
The facility failed to provide written bed hold notices for three residents hospitalized for various medical conditions, including a stroke, peripheral vascular disease, and cardiorespiratory issues. Despite the facility's policy requiring such notifications, records lacked evidence of compliance, as confirmed by interviews with staff.
A facility failed to ensure a resident received routine physician visits every 60 days, as required. The resident, with diagnoses including stroke and diabetes, only had documented visits on two occasions, resulting in a gap exceeding 60 days. The facility's policy mandates visits every 30 days for the first 90 days and every 60 days thereafter, with a 10-day grace period, but the resident's record lacked evidence of compliance.
The facility failed to offer the pneumococcal vaccine series to two residents as recommended by the CDC. One resident with a history of stroke and other conditions had received PPSV23 in 2014, but there was no evidence of a decision-making process for PCV20. Another resident with respiratory failure and kidney disease had received PCV13 and PPSV23 but lacked documentation for PCV20. The DON and IP confirmed the oversight, noting that immunizations should be reviewed during care conferences.
Failure to Use PPE During Soiled Laundry Sorting
Penalty
Summary
The facility failed to ensure proper use of PPE while sorting soiled linens and personal laundry. During observation of the laundry room, no PPE was seen anywhere in the dirty linen sorting area. The housekeeping supervisor confirmed that staff do not wear the required PPE when sorting soiled laundry and stated they only wear gloves, with no other items, and that this had been the practice since they began working in the laundry room the previous year. The administrator stated the expectation was for staff to wear full PPE, including gown, gloves, and goggles, while sorting laundry, and later stated the facility did not have a laundry policy.
Uncovered catheter bag exposed during ambulation
Penalty
Summary
The facility failed to ensure privacy for 1 of 1 resident reviewed for dignity. R101, who was admitted with diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, and infection and inflammatory reaction due to indwelling urethral catheter, was observed ambulating with OT-A while an uncovered urinary catheter bag was hanging on the lowest bar of the wheeled walker. R101 and OT-A walked down the hallway past the nurse's station and dining room and past 2 staff and 2 residents before R101 sat down to rest. During interview, OT-A stated she forgot to move the privacy bag with the catheter bag to the walker and said catheter bags should remain covered for resident privacy. R101 stated a preference to have the catheter bag covered when in public areas. RN-A stated catheter bags were to be covered and said, "It's a dignity issue." A catheter policy was requested, but none was provided.
Medication Order and Card Mismatch for Morphine
Penalty
Summary
The facility failed to follow standards of practice for medication management for one resident during medication administration. During observation, the resident’s EMAR showed a Morphine Sulfate order for a 15 mg tablet with a dose of 2.5 mg to be given sublingually every 3 hours, while the pharmacy medication card showed a 2.5 mg sublingual tablet to be given every 6 hours. RN-A confirmed the order and the card did not match and stated this tended to happen with sublingual tablet orders. RN-A also confirmed the facility did not use the dose-change sticker on the card, even though they had one available, and continued to use the card because the dose matched. The resident’s record showed severe cognitive impairment and diagnoses including atrial fibrillation, coronary artery disease, heart failure, hypertension, diabetes, Alzheimer’s, anxiety, arthritis, and non-Alzheimer’s dementia. The hospice physician order form showed Morphine 2.5 mg solutab, 1 tablet under the tongue every 3 hours for pain, while the order summary report listed Morphine Sulfate 15 mg tablet, give 2.5 mg sublingually every 3 hours for pain. The pharmacy confirmed the tablet strength had likely been selected incorrectly when ordering and stated the cards and orders were expected to match. The DON confirmed the orders had been reviewed by two nurses, but the transcribed orders still did not match and staff had not used the order/dose change sticker.
Pharmacy Recommendation Not Entered for BP Medication Hold Parameters
Penalty
Summary
The facility failed to ensure pharmacy recommendations were addressed for one resident reviewed for unnecessary medications. The resident had a quarterly MDS indicating severe cognitive impairment and diagnoses including HTN, renal insufficiency, diabetes, thyroid disorder, non-Alzheimer's dementia, and a stroke. The resident's physician orders showed three HTN medications: Metoprolol Succinate ER 50 mg daily, Lisinopril 40 mg daily, and Amlodipine Besylate 10 mg at bedtime. A monthly pharmacy recommendation requested hold parameters for the three HTN medications, and the provider signed the recommendation with orders for HOLD if SBP was 100 or less. The order was reviewed and signed by two nurses, but the medical record had no evidence the parameters were ever added to the medication orders. The RNC confirmed the hold parameters were never entered into the electronic charting system, and the pharmacist confirmed the parameters were never entered as ordered. The DON stated the pharmacy emailed monthly recommendations to the DON and nurse managers were responsible for follow-up, and confirmed the parameter orders for the resident were never entered.
Binding Arbitration Agreement Not Clearly Explained
Penalty
Summary
The facility failed to ensure a binding arbitration agreement was clearly communicated in a form and manner understood by a resident prior to signing. Resident R43’s admission MDS indicated intact cognition, diagnoses of non-Alzheimer’s dementia, moderate vision impairment, and a need for someone to help read written materials. Exhibit H, the undated Binding Arbitration Agreement, contained R43’s signature. During interview, R43 stated he would not have signed a binding arbitration agreement, said legal issues at the time of admission would have prevented him from signing, and stated he was not able to read or write and would therefore require assistance. During interviews, social services staff stated he completed the binding arbitration with R43 and explained it as a legal form that would speed up the process if residents brought the facility to court, while stating he would not have told residents they were giving up any rights. He also stated he had limited training on binding arbitration and had been responsible for all such agreements until they were transferred to the admission coordinator on 5/1/26. The admission coordinator stated she presented binding arbitration upon admission and would stop and discuss it with family if a resident did not understand. The Administrator stated all binding arbitration agreements were grandfathered in. A facility document titled Explanation of Arbitration Agreement Language to Family and Resident/Patient stated arbitration does not occur in a court, but it lacked indication that the agreement was explained in a form and manner the resident or representative understood, including in a language they understood, and lacked resident or representative acknowledgement of understanding.
Failure to Offer and Provide Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure 2 of 5 residents reviewed for immunizations, R11 and R76, were offered, educated about, and/or provided the pneumococcal vaccination series as recommended by the CDC. A CDC Adult Immunization Schedule dated 08/07/2025 identified that adults who had not received the complete pneumococcal series, or whose history was unknown, may receive PCV20, PCV15, or PCV21. The facility's Pneumococcal policy, last revised 2/24, required residents to be assessed for current immunization status and eligibility prior to or upon admission, and to be offered the vaccine within 30 days of admission unless already vaccinated or medically contraindicated. R11's quarterly MDS showed R11 was admitted at [AGE] years old with severe cognitive impairment and diagnoses including HTN, renal insufficiency, DM, non-Alzheimer's dementia, depression, malnutrition, and psychotic disorder other than schizophrenia. R11's vaccination record indicated R11 was due for the next pneumonia vaccination, and an immunization informed consent form signed 12/3/25 showed consent for PCV20, but the medical record lacked evidence the vaccine was ever given. R76's quarterly MDS showed R76 was admitted at [AGE] years old, cognitively intact, with diagnoses including HTN, neurogenic bladder, DM, paraplegia, seizure disorder, depression, malnutrition, and bipolar disorder. R76's vaccination record also indicated the resident was due for the next pneumonia vaccination, but the record lacked evidence PCV20 was provided, and the signed consent form dated 9/23/25 stated R76 had not been offered the PCV20 vaccination. The regional nurse consultant stated on 6/16/26 that neither resident had been offered PCV20 and that it had been missed, with the expectation that vaccinations be offered and provided upon admission.
Failure to Update Care Plan with Fall Interventions
Penalty
Summary
The facility failed to update the care plan with specific interventions following two separate falls experienced by a resident with severe cognitive impairment and significant care needs. After falls on two consecutive days, documentation indicated that interventions such as PRN medications, frequent rounding, and hospice review for medication side effects were implemented. However, these interventions were not incorporated into the resident's care plan as required. The most recent care plan revision did not reflect these new interventions, despite documentation and policy indicating that such changes should be made and communicated to staff. Interviews with facility staff, including a nursing assistant, an LPN, and an RN, confirmed that the care plan was the primary source for fall interventions and that the management team was responsible for updating it. The RN acknowledged that the new interventions following the falls should have been added to the care plan but were not. The administrator also confirmed that staff were expected to refer to the care plan for fall interventions and that management was responsible for timely updates. The facility's Post Fall Assessment policy required care plan changes to be made and communicated as appropriate, which did not occur in this instance.
Failure to Sustain Ongoing Compliance with QAPI for Repeat Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assurance Assessment and Performance Improvement Plan (QAPI) committee effectively sustained ongoing compliance regarding previously cited deficiencies. Specifically, the facility was cited for repeat deficiencies in quality of care, development and implementation of comprehensive care plans, and self-administration of medications (SAM). These deficiencies were identified during the current survey and had also been cited in a previous survey. For quality of care, the facility did not follow current physician orders and parameters for two residents reviewed for medications. In the area of care planning, the facility did not develop or maintain a care plan to ensure appropriate care for a resident with increased care needs due to decline. Regarding SAM, the facility failed to complete a self-administration of medications assessment for a resident observed with medications at bedside. Review of QAPI meeting minutes over several months showed a lack of ongoing data and tracking related to these repeat citations. The administrator confirmed that the facility had not been monitoring previous compliance with surveys and only recently began to form a plan to address and maintain compliance. The facility's QAPI policy required the development, implementation, and evaluation of corrective actions or performance improvement activities, but this was not demonstrated in practice for the cited areas.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to complete a self-administration of medications (SAM) assessment for a resident who was observed with medications at bedside. The resident had intact cognition and multiple diagnoses, including cancer, malnutrition, asthma, chronic obstructive pulmonary disease, and required oxygen therapy. The resident was prescribed antipsychotic, antianxiety, antidepressant, and narcotic pain medications, as well as nebulizer treatments and supplemental oxygen. Despite these needs, there was no documentation of a SAM order or assessment in the resident's medical record, medication administration record, or care plan. During observation, a nebulizer machine with a cup two-thirds full of solution and an empty medication vial were found in the resident's room, accessible to the resident. Nursing staff confirmed that the resident did not have a SAM order or assessment and that the nebulizer should not have been left for self-administration. Facility policy requires an interdisciplinary team assessment and care plan documentation before allowing self-administration of medications, which was not completed in this case.
Failure to Update Care Plan Following Resident Decline
Penalty
Summary
A deficiency occurred when the facility failed to update the care plan for a resident experiencing a significant decline in condition. The resident, who had diagnoses including terminal lung cancer, malnutrition, asthma, and chronic lung disease, was previously independent with activities of daily living (ADLs) such as bathing, toileting, and dressing, as documented in her care plan and bedside Kardex. However, observations over several days showed the resident was increasingly dependent, remaining in bed, unresponsive to verbal stimulation, and wearing the same clothing for multiple days. Staff interviews confirmed that the resident now required assistance with all personal cares, including bathing, toileting, and dressing, due to her declining condition. Despite these changes, the care plan and Kardex were not updated to reflect the resident's increased need for assistance. Nursing staff, including the registered nurse and CNA, acknowledged that the care instructions in the Kardex were outdated and did not match the resident's current needs. The nurse manager and DON both confirmed that the care plan had not been revised to address the resident's decline, even though facility policy required care plans to be reviewed and updated upon a change in status. The facility's own policy outlined a process for reviewing and revising care plans when a resident experiences a status change, including notification of the MDS coordinator, collaboration with the interdisciplinary team, and communication of updated interventions to all staff. However, this process was not followed in the case of this resident, resulting in a care plan that did not accurately reflect her current care needs.
Failure to Provide Nail and Grooming Care for Dependent Resident
Penalty
Summary
A resident with moderate cognitive impairment, impaired mobility, and a self-care deficit requiring assistance with all activities of daily living (ADLs) did not receive appropriate nail care. The resident was observed on multiple occasions to have long, irregular fingernails that extended past the fingertips, with dark matter occasionally visible under the nails. The resident expressed dissatisfaction with the length of his fingernails, stating they sometimes got caught on his sheets, and reported being unable to shave due to not having an appropriate razor. Despite having requested an electric razor weeks prior, the resident had not received one. The care plan indicated the resident was at risk for excessive bruising and bleeding due to the use of a blood thinner, and required assistance with all ADLs, including grooming and nail care. Interviews with staff confirmed that nail care should be completed on bath days or as needed, and that assistance with grooming was expected daily. Staff acknowledged that the resident's nail care had not been performed as required, and that documentation and follow-up were lacking when care was refused or not completed. Facility policy stated that necessary services for ADLs, including bathing and grooming, would be provided for residents unable to complete these tasks. The deficiency was identified through observation, resident and staff interviews, and review of care plans and facility policy.
Failure to Follow Physician Orders and Medication Parameters for Two Residents
Penalty
Summary
The facility failed to follow current physician orders and medication parameters for two residents reviewed for medications. For one resident with moderate cognitive impairment and diagnoses including gastroparesis, malnutrition, and fecal impaction, the most recent signed physician orders specified prochlorperazine as needed for nausea, polyethylene glycol once daily, and metoprolol tartrate with instructions to hold if systolic blood pressure was less than 100. However, the medication administration record (MAR) showed these medications were administered at different dosages and frequencies, and without the specified parameters. Additionally, there was no documentation of blood pressure readings for several months, despite the requirement to monitor before administering metoprolol. Another resident, who was cognitively intact and had diagnoses including neuromyelitis optica and diabetes, had signed physician orders for tacrolimus at specific dosages, hydralazine and carvedilol with instructions to hold if mean arterial pressure (MAP) was less than 65. The MAR reflected administration of tacrolimus at a different dosage and did not include documentation of MAP or pulse prior to administration of hydralazine and carvedilol. Staff interviews revealed confusion regarding the MAP parameter, with some staff indicating they would check heart rate instead, and others acknowledging unfamiliarity with MAP calculations. The facility did not routinely compare the most recent signed physician orders with the MAR, leading to discrepancies in medication administration. The facility's policy required new orders to be entered onto the MAR and verified with the attending physician if unclear, but this process was not consistently followed. The consultant pharmacist failed to identify discrepancies during monthly medication reviews, and the director of nursing confirmed that medication parameters were not always followed and that discrepancies between signed orders and administration were not recognized. The facility did not adhere to its own procedures for reviewing and reconciling physician orders, resulting in residents receiving medications in a manner inconsistent with current orders and parameters.
Failure to Provide Range of Motion Care After Family Request
Penalty
Summary
A resident with diagnoses including neuromyelitis optica, diabetes, and encephalopathy was dependent on staff for activities of daily living such as dressing, eating, and oral hygiene. The resident's care plan noted a need for assistance with ADLs due to impaired mobility and weakness, but did not include specific interventions for range of motion (ROM) exercises. Documentation showed that the resident had been discharged from physical and occupational therapy several months prior, and no new therapy referral was made despite a significant change in condition and a family request for ROM therapy due to stiffness. Interviews with staff confirmed that ROM exercises would be documented if performed and that therapy referrals should be made following a change in condition or family request. The nurse manager and DON both acknowledged that a therapy referral should have been initiated after the family's request, and that ROM interventions should have been included in the care plan or Kardex. Facility policy required assessment of ROM and referral to therapy as appropriate, but these steps were not followed, resulting in a failure to provide necessary ROM care for the resident.
Consulting Pharmacist Failed to Identify and Report Medication Parameter Irregularities
Penalty
Summary
The consulting pharmacist failed to identify and report irregularities related to physician-ordered medication parameters for two residents during monthly drug regimen reviews. For one resident with moderate cognitive impairment and diagnoses including gastroparesis, malnutrition, and fecal impaction, physician orders required metoprolol to be held if systolic blood pressure was less than 100. However, the medication administration record showed the medication was given without documentation of blood pressure checks, and the order on the MAR did not include the hold parameter. Over the previous six months, pharmacy reviews did not identify that the blood pressure parameter was not being followed. For another resident with neuromyelitis optica and diabetes, physician orders required hydralazine and carvedilol to be held if mean arterial pressure (MAP) was less than 65. The MAR showed hydralazine was administered with blood pressure recorded instead of MAP, and carvedilol was given without any vital signs documented. The consulting pharmacist did not identify that MAP parameters were not being followed or recommend reviewing the appropriateness of using MAP as a parameter in this setting. Interviews with facility staff and the medical director confirmed that MAP is not a standard parameter in nursing homes and that the pharmacist failed to recognize and report these discrepancies during monthly reviews.
Failure to Assess Resident's Capacity to Consent
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents, R1 and R2, by not assessing R1's capacity to consent prior to the incident. On the evening of the incident, staff found R1 and R2 being sexually intimate in R1's room. Although the residents were monitored throughout the night and an investigation was initiated, the facility did not adequately assess R1's ability to consent to sexual activity, given her severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 4. R1's medical records and care plan indicated she had severe cognitive impairment due to dementia, requiring assistance with daily activities and communication. Despite this, the facility's investigation report noted that both residents were seen by a psychologist who found them alert and oriented, capable of making decisions about physical/sexual contact. However, a subsequent psychiatry assessment determined that R1 lacked the capacity to consent to sexual expression, contradicting the facility's earlier findings. Interviews with staff and family members further highlighted R1's confusion and memory issues, reinforcing concerns about her ability to consent. The facility's decision-making process regarding R1's capacity to consent was inconsistent and lacked a comprehensive assessment. The administrator and director of social services relied on R1's verbal consent and the absence of distress as indicators of her capacity, despite evidence of her cognitive limitations. The facility did not have a specific policy on assessing residents' capacity to consent, which contributed to the inadequate investigation and response to the incident.
Failure to Assess Capacity to Consent in Residents with Cognitive Impairment
Penalty
Summary
The facility failed to comprehensively assess a resident's capacity to consent to sexual activity, leading to a deficiency. The incident involved two residents, one with severe cognitive impairment and the other with mild cognitive impairment, who were found being sexually intimate. The facility's report to the State Agency indicated that the residents were monitored, and an investigation was initiated. However, the resident with severe cognitive impairment, identified as having a BIMS score of 4, was not appropriately assessed for capacity to consent prior to the incident. The resident's care plan acknowledged her severe cognitive impairment and directed staff to assist in removing her from dangerous situations and to communicate with her family regarding her capabilities. Despite this, the care plan also noted that the resident consented to a relationship with the other resident. A psychiatry assessment later identified that the resident lacked the capacity to consent to sexual expression, but this assessment was not conducted prior to the incident. Interviews with staff and family members revealed that the resident often exhibited confusion and memory issues, further questioning her ability to consent. The facility's administrator and social services director conducted interviews and held a care conference, ultimately deciding that the residents could maintain a relationship. However, the decision was based on the resident's verbal consent and lack of distress, rather than a thorough assessment of her cognitive capacity. The facility lacked a specific policy on assessing capacity to consent, and the deficiency was identified due to the absence of a comprehensive assessment prior to the incident.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for three residents reviewed for hospitalization. Resident 3, who had a significant change in their Minimum Data Set (MDS) indicating diagnoses such as cerebrovascular accident, diabetes, anemia, malnutrition, and epilepsy, was hospitalized from April 28 to May 17, 2024. However, there was no evidence in Resident 3's record that the Ombudsman for LTC was notified of this transfer. Similarly, Resident 4, with diagnoses including peripheral vascular disease, MRSA infection, and pressure ulcers, was hospitalized from March 28 to April 2, 2024, without notification to the Ombudsman. The document faxed to the Ombudsman for March 2024 also lacked this information. Resident 5, with multiple diagnoses including cardiorespiratory conditions, atrial fibrillation, cirrhosis, and respiratory failure, was hospitalized on an unspecified date, and the progress notes did not indicate notification to the Ombudsman. Additionally, Resident 5 was discharged from the facility on May 8, 2024, but the Ombudsman was not notified of this discharge either. The facility's policy on transfers and discharges, last reviewed in October 2023, only mentioned notifying the Ombudsman of discharges, not hospital transfers. During an interview, the social services director admitted to being unaware of the requirement to notify the Ombudsman of hospital transfers.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide written notice of a bed hold upon transfer for hospitalization for three residents. Resident 3, who had a history of cerebrovascular accident, diabetes, anemia, malnutrition, and epilepsy, was transferred to the emergency department for a gastrostomy tube replacement and subsequently admitted to a hospital. Despite the hospitalization from April 28 to May 17, there was no evidence of a written bed hold notice in Resident 3's records. Similarly, Resident 4, with diagnoses including peripheral vascular disease and MRSA infection, was hospitalized from March 28 to April 2, but their records also lacked a written bed hold notice. Resident 5, who had multiple diagnoses including cardiorespiratory conditions and atrial fibrillation, was hospitalized, yet there was no documentation of a bed hold policy notification to the resident or responsible party. Interviews with facility staff, including the Executive Director, Social Services Director, and Director of Nursing, confirmed the absence of bed hold notifications in the residents' records. The facility's policy required that bed hold and readmission policies be provided before transferring a resident to a hospital or for therapeutic leave, with emergency transfers requiring notification within 24 hours. However, the records for Residents 3, 4, and 5 did not contain the necessary documentation, indicating a failure to adhere to the facility's policy.
Failure to Ensure Routine Physician Visits
Penalty
Summary
The facility failed to ensure that a long-term resident received routine physician visits every 60 days, as required. The resident, who had a significant change Minimum Data Set indicating diagnoses of cerebrovascular accident, diabetes, anemia, malnutrition, and epilepsy, only had documented physician visits on two occasions: 2/5/24 and 5/22/24. This resulted in a gap of more than 60 days between visits, with no evidence of a visit occurring within the required timeframe. The facility's policy mandates that physician visits occur every 30 days for the first 90 days after admission and every 60 days thereafter, with a 10-day grace period. However, the resident's clinical record lacked evidence of compliance with this policy, as confirmed by the Director of Nursing and the Infection Preventionist.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that two residents, identified as R3 and R9, were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. R3, who had a history of cerebrovascular accident, diabetes, anemia, malnutrition, and epilepsy, had received the PPSV23 vaccine in 2014. However, there was no evidence in R3's records of shared clinical decision-making with a physician regarding the administration of the PCV20 vaccine, which should have been considered at least five years after the last pneumococcal dose. Similarly, R9, with diagnoses including acute and chronic respiratory failure and chronic kidney disease, had received PCV13 in 2016 and PPSV23 in 2018. R9's records also lacked evidence of shared clinical decision-making for the PCV20 vaccine. The director of nursing and the infection preventionist confirmed that the records for both R3 and R9 did not show that they were offered, declined, or received the PCV20 vaccine. The infection preventionist noted that immunizations should have been reviewed during care conferences to determine eligibility and offer the PCV20 vaccine, which is important for fighting pneumonia and reducing infection effects. The facility's policy, reviewed in October 2023, stated that immunizations should be provided in accordance with CDC guidelines, indicating a failure to adhere to these guidelines in the cases of R3 and R9.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,041 citations issued within 25 miles in the last 12 months — including the 28 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near St Anthony
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crest View Lutheran Home | 1.5 mi | ★★★★★ | 2 | 0 |
| Presbyterian Homes Of Arden Hills | 1.6 mi | ★★★★★ | 1 | 0 |
| Bywood East Health Care | 1.8 mi | ★★★★★ | 21 | 1 |
| New Brighton Care Center | 2 mi | ★★★★★ | 12 | 0 |
| The Villas At New Brighton | 2.2 mi | ★★★★★ | 14 | 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 August 2026) and official state health department websites.