St Anthony's Adult Care Home, LLC

Based on document review and interview, the governing authority failed to ensure the health, safety, or welfare of a resident was not placed at risk of harm. The deficient practice resulted in actual harm to a resident. Findings include: 1. A review of R1’s medical record revealed progress notes for August 2025, into September 2025. Notes entered by E3, on August 28, 2025, indicated R1’s family member brought in a heating pad for R1, and instructed E3 on how to use the pad. Notes entered on the same day, by E4 reflect E4 advised R1 the heating pad “may burn you skin.” Entries on August 29, 30, 31, September 1, 2, and 3, 2025, reflect R1 was still using the heating pad at night. Notes during this date range also reflect caregivers were unplugging or turning off the heating pad, against R1’s wishes. A note on September 4, 2025, indicated E3 found burns on R1’s back from the use of a heating pad. 2. In an interview, E1 advised R1’s relative was informed the facility did not use heating pads because they were dangerous. E1 said R1’s relative brought in a heating pad for R1 anyway. E1 reported R1 was complaining of being cold, and would become mad when caregiver’s turned the heating pad off. E1 stated they allowed R1 to use the heating pad because E1 was concerned of violating R1’s right to use their own heating pad if they chose to. E1 acknowledged they placed R1’s health, welfare and safety at risk by allowing R1’s continual use of a heating.

Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified a resident's primary care provider or emergency contact when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of R1’s medical record revealed progress notes for August 2025, into September 2025. Notes throughout the month of August reflect R1 was regularly using a heating pad, brought into the facility by R1’s family member. A note on September 4, 2025, indicated E3 found burns on R1’s back from the use of a heating pad. The note did not include a description of the injury to R1’s back. The note indicated R1’s hospice provider and R1’s emergency contact were notified; however, the note did not indicate what time they were notified. Notes did indicate the hospice nurse arrived to the facility at approximately 11:00 a.m. 2. A review of facility incident reports revealed no evidence of documentation of any incident report pertaining to R1. 3. In an interview, E3 advised E3 discovered the injuries to R1’s back at approximately 7:00 a.m. E3 said they contacted R1’s hospice provider but did not contact R1’s primary care provider. E3 indicated they did contact R1’s emergency contact, but did not note what time they were contacted. 4. In an interview, E1 agreed there was no evidence to indicate emergency contacts and/or primary care providers were immediately notified for incidents in which R1 suffered an injury requiring medical services.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed a metal cabinet on the back patio of the facility. The cabinet was equipped with a locking hasp; however, the locking mechanism was not engaged. The Compliance Officer opened the cabinet and observed a large bottle of Fabuloso Multi-purpose cleaner, a bottle of “Member’s Mark Commercial Sanitizer,” and a spray can of “Raid Flying Insect” insecticide. Each of the containers was marked “CAUTION KEEP OUT OF REACH OF CHILDREN.” 2. In an interview, E1 acknowledged cleaners and insecticide were not kept in a secure area, inaccessible to residents.