St. Anthony Healthcare Center: Wound Care Delay - MI
The resident, identified in inspection records as R701, was admitted on August 13, 2025, discharged from a hospital that had already documented bilateral foot and ankle deep tissue pressure injuries. The injuries were not identified at St. Anthony until August 28. For those 15 days, there were no treatment orders, no documented measurements, no interventions of any kind.
A deep tissue pressure injury is not a subtle finding. It appears as a discolored patch of intact or broken skin, often purple or maroon, that signals damage to the tissue underneath. The feet and ankles are among the most common sites. The injuries had already been documented by the discharging hospital before R701 ever arrived at the facility.
The unit manager covering R701's room at the time of admission was LPN C. When inspectors interviewed LPN C on September 9, 2025, at 2:30 in the afternoon, the nurse described what a proper admission assessment should look like: thorough, covering the entire body, with any skin concerns documented regardless of whether they were new or already present. That is what should have happened. It did not.
The Director of Nursing said the same thing when inspectors spoke with her at 3:00 that afternoon. Initial skin assessments should cover the entire body. Any concerns identified should have treatment orders put in place immediately. She offered no explanation for why R701's wounds had gone unnoticed for more than two weeks.
The facility's own written policy, dated September 19, 2024, spelled out the expectation plainly. Every resident admitted or readmitted receives a baseline total body skin evaluation, documented in the electronic medical record. Any resident arriving with a skin impairment gets appropriate interventions, a physician's treatment order, and documentation of the wound's location, measurements, and characteristics. R701 arrived with documented impairments on both feet and both ankles. None of those steps happened at admission.
What makes the 15-day gap difficult to explain is that the information was not hidden. The hospital discharge paperwork identified the injuries. Someone at the sending facility had already looked at R701's feet and written down what they saw. The question inspectors were left with is not how the wounds developed undetected, but how a nursing staff completing an admission assessment missed injuries that were already in the chart.
The inspection was conducted as a complaint investigation. The deficiency was cited under F0686, which covers the prevention and treatment of pressure injuries. CMS rated the level of harm as minimal harm or potential for actual harm, with few residents affected.
That rating reflects the regulatory classification, not necessarily what 15 days without treatment meant for R701. Deep tissue pressure injuries can deteriorate. Tissue that appears intact at the surface can break down. The window between identification and intervention matters. R701 went without either for more than two weeks after walking, or being wheeled, through the front door.
LPN C and the Director of Nursing both described the same standard. Both said it clearly. Neither offered an account of what went wrong on August 13, or on any of the 14 days that followed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Anthony Healthcare Center from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
St. Anthony Healthcare Center in Warren, MI was cited for violations during a health inspection on September 9, 2025.
The injuries were not identified at St.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.