Ascension Resurrection Life

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents and staff documentation of screening, education, offering, and current COVID-19 vaccination status. These failures are not in accordance with their policies and procedures and CDC (Centers for Disease Control and Prevention) guidelines. Multiple residents and facility staff were positive of Covid infection that were either not up to date with COVID-19 immunization or unvaccinated that can potentially affect all 51 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide interventions to prevent a resident from developing wounds due to immobilizer/brace skin friction. Facility also failed to consistently document physician orders were being followed/given on the treatment administration record (TAR) and on the medication administration record (MAR) for 1 (R1) out of 3 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to contain oxygen equipment (nebulizer mask) per facility's policy. This failure affected one residents (R6) reviewed for oxygen equipment, in total sample size of 11 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene and don the required Personal Protective Equipment (PPE) when providing care for three residents who required Enhanced Barrier Precautions (EBP). These failures affected three residents (R1, R10 and R11).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that food is labeled with a date the food was opened and a date the food expires. These failures have the potential to affect 131 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident (R11) who was later identified with a serious mental disorder or related condition to the appropriate state-designated authority for a Level II PASARR (Pre-admission Screening and Resident Review) evaluation and determination for one out of 26 residents reviewed for PASARRs.

Inspectors wroteBased on observation, interview and review of record, the facility has the following failures related to pharmaceutical services: the facility failed to follow their policy and store controlled substances in a safe and secure manner and ensure an accurate controlled drug form for R129. This was true for 2 out of 4 medication carts reviewed for medication storage. Facility also failed to administered medicine properly by leaving medication at the bedside. Failed to administer medications as ordered by physician. These failures apply to 8 residents (R24, R57, R61, R67, R93, R102, R129, R143) receiving pharmaceutical services in the facility that may affect their healthcare needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow call light policy and procedure on accessibility of call light for 1 out of 1 resident (R102) for a total sample of 26 residents reviewed for environment.

Inspectors wroteBased on observation, interview and review of record, the facility failed to meet quality of care of professional standards related to pharmaceutical services for 2 (R57 and R61) out of 26 residents in the sample reviewed for quality of care.

Inspectors wroteBased on observation, interview, and review of record, the facility failed to follow the facility's medication administration policies. The facility also failed to follow physician order instruction during medication administration of 1 out of 6 residents (R61). There were thirty-one (31) opportunities with 6 errors resulting in 19.35% error rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and store all drugs and biologicals in a safe and secure manner. This was true for 2 out of 4 medication carts and 1 out of 4 medication rooms reviewed for medication storage.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure PPE (Personal Protective Equipment) was properly disposed of before the staff member exited one (R42) resident on EBP (Enhanced Barrier Precautions) room and failed to ensure PPE was donned when changing the linen for one (R69) resident on EBP. Findings Include: R42 has diagnosis not limited to Cellulitis of Right lower Limb, Lymphedema and Sepsis. R42's Physician's Orders document in part: Midline Insertion, Wound Care Right Knee and Wound Care Right Lower Leg. Enhanced Barrier Precautions, IV (Intravenous) therapy. R42's Care Plan document in part: Pressure Ulcers/Skin Prevention: R42 has right lower extremity cellulitis with open wounds to right lower extremity. Infection and IV's: R42 is on antibiotic therapy for cellulitis on bilateral lower extremities. [...]

Inspectors wroteBased on interview and record review, the facility failed to clean and empty a resident's ileostomy bag in a timely manner. The facility also failed to ensure an accurate skin assessment upon admission. These failures affect one (R1) out of three residents reviewed for ostomy care.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of residents who were transferred or discharged back to the community or to another nursing facility. This failure has the potential to affect residents transferring or discharging out of 124 residents residing in the facility. Findings Include:On 8/17/25 at 9:28 AM, V4 (Social Worker) stated that he emails V13 (Facility Ombudsman) once a week of the list of residents who are hospitalized . V4 stated he does not send notification of the other discharges such as residents who are discharged back to the community because it is not required. Email receipts provided by V4 reviewed and revealed V4 sent the list of hospitalized residents not including other transfers or discharges to V13 on these dates: 8/10/25, 8/1/25, 7/9/25, and 3/27/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy of transferring a resident via a mechanical lift. This failure affected 1 (R1) resident reviewed for supervision in the total sample of 3 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide person-centered discharge plan of care for 5 out 5 residents (R1, R2, R3, R4 and R5) reviewed for care plan.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and failed to follow the Care Plan implementing fall prevention interventions to one resident (R1) reviewed for resident injury. This failure resulted in R1 falling and sustaining bilateral subdural hemorrhages and a right parietal subarachnoid hemorrhage. R1 was admitted to the intensive care unit.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) ensure all food items were labeled with an opened and use by date, b.) discard expired food based on use by date documented on label, c.) follow manufacturer guidelines for storage. These failures have the potential to affect all 132 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to dispose eye drops after the discard date, refrigerate an unopened insulin pen, and lock a medication cart when not in use or in view for two out of four carts reviewed for medication storage and labeling. The facility also failed to properly dispose of R76's controlled medication after opening and failed to ensure controlled medications for R64 were under a double lock for 1 of 4 medication carts and 1 of 2 medication rooms reviewed for medication storage and labeling.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) follow their policies by not wearing the appropriate Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) during high-contact resident care activities for 4 (R8, R28, R54, R223) residents and b.) handle and contain soiled linen during linen changing and transport. These failures have the potential to affect all residents residing on the first floor and second floor units. Findings Include: 1.) R28 has diagnosis not limited to Acute Embolism and Thrombosis of Femoral Vein, Bilateral, Localized Edema, Polyneuropathy, Unsteadiness on feet, Mature T/NK-Cell Lymphoma, Muscle Spasm, Thrombocytopenia and Heart failure. R28's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call light was within reach for one (R32) out of eight residents reviewed in a total sample of 26 for call lights.

Inspectors wroteBased on interview and record review the facility failed to follow their discharge against medical advice policy for 1 (R120) resident reviewed for discharge in a sample of 26. Findings Include: R120 was admitted to the facility on [DATE] with diagnosis not limited to Epilepsy, Mild Intermittent Asthma, Unspecified Fall, Obesity, Syncope and Collapse and Unilateral Primary Osteoarthritis. Based on review of R120's progress note, R120 was admitted to the facility at 04:00 PM on 08/05/24 and left the facility AMA (Against Medical Advice) on 08/05/24 at 07:30 PM. Progress note dated 08/05/24 10:26 PM document in part: Resident admitted at 4 pm with dx (diagnosis) multiple falls at home with head injury. 7 staples intact to the back of the head. Syncope, epilepsy, seizure disorder, elevated troponin, obesity, asthma, right knee pain, osteoarthritis. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's initial preadmission screening was completed prior to admission to the nursing facility for 1 (R40) out of 2 sampled residents reviewed for Preadmission Screening and Resident Review (PASARR). Findings Include: R40's clinical records show an initial admission date of 3/27/24 with included diagnoses not limited to Major Depressive Disorder, Bipolar Disorder and Generalized Anxiety Disorder. R40's Notice of PASRR Level I Screen Outcome shows a review date of 8/14/24. On 10/02/24 at 9:52 AM, interviewed V15 (Business Development Coordinator) and stated that R40's PASARR was done after admission because R40 came from home. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow a resident's (R64's) and their representative's wishes for no hospitalization for 1 out of 3 residents reviewed for hospice.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to correctly set an air loss mattress based on weight for one (R32) of 8 residents reviewed in a total sample of 26 for pressure wound treatment services.

Inspectors wroteBased on interviews and records reviews, the facility failed to follow the fall care plan intervention for one resident (R98) of 8 residents reviewed for falls out of a total sample of 26. Findings Include: R98's diagnosis includes but not limited to Unspecified Dementia with Agitation, Repeated Falls, Anxiety Disorder. R98's clinical records show R98 has a history of multiple falls. R98's Minimum Data Set (MDS) dated [DATE] shows R98 had severe cognitive impairment and requires partial/moderate assistance with chair to bed to chair transfer. R98's fall care plan documents in part, resident is at risk for falls due to impaired mobility and weakness, moderate vascular dementia with mood disturbance and resident takes psychoactive medications. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy and procedure to ensure a.) oxygen equipment was dated and changed weekly, b.) physician orders for oxygen administration rate were followed, c.) nebulizer equipment was stored in a plastic bag with the resident's name and date on it when not in use. These failures have the potential to affect two (R9, R273) of eight residents reviewed for respiratory care in a total sample of 26.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident (R221) was free of any significant medication errors for one out of five residents reviewed for medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve mechanical soft food to a resident on mechanical soft diet order. This failure affected 1 (R19) of 4 residents reviewed for mechanical soft diet prepared in the facility's kitchen, in a total sample of 26 residents. Findings Include: On 10/01/24 at 11:26 AM, observed R19 eating in the unit dining room. R19 had a large plate of salad with raw Romaine lettuce, tomato wedges, chopped hardboiled egg, bacon pieces and chunks of chicken. Observed R19 putting a piece of lettuce and bacon in R19's mouth and then using R19's fingers to take the lettuce and bacon back out of R19's mouth and placing the semi chewed lettuce and bacon on the side of R19's plate. [...]

Inspectors wroteBased on observations, interviews, and records review, the facility failed to follow their Discarding and Destroying Medications policy, and failed to assure that medications to be disposed were secure and inaccessible to unauthorized staff and residents. These failures have the potential to affect 80 residents living on the first floor that may be able to access the unsecured room.

Inspectors wroteBased on observation, interview, and records review, the facility failed to follow infection control policy by failing to properly dispose of used needles, contaminated blood draw equipment, failed to secure the contaminated equipment by over filling the sharps containers and leaving needles and contaminated tubing exposed, failed to properly close sharps containers by leaving them without top covers while filled with sharps. This deficiency has the potential to affect all 80 residents living on the first floor.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident remain free from abuse, for one of three (R1) residents reviewed for abuse. This failure resulted in R1 being physically abused by a Certified Nursing Assistant. This past noncompliance occurred from 11/9/2023 to 11/11/2023.

Inspectors wroteBased on interviews and records review, the facility failed to ensure a Certified Nursing Assistant/CNA possessed the competencies and skill sets necessary to provide nursing and related services in a safe manner for one (R1) resident of three reviewed. This failure resulted in a CNA physically abusing (hitting) R1. This past noncompliance occurred from 11/9/2023 to 11/11/2023.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to make reasonable accommodations for two (R1, R2) of four residents. This failure resulted in R1 sustaining a facility acquired pressure ulcer to left heel.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to follow their wound prevention policy for two residents (R1, R2). The facility failed to ensure one (R1) did not develop a pressure wound. The facility also failed to ensure R2 did not develop bilateral reddened heels despite being on a low air loss mattress. This failure resulted in R1 developing a deep tissue pressure injury to his left heel.

Inspectors wroteBased on observation, interview and record review the facility failed to provide group activities to meet the needs and interests of 1 resident (R1) out of 3 reviewed for resident rights. This failure resulted in R1 having limited interaction with peers and resident feeling isolated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discard outdated medications for 2 (R9 and R16) residents. The facility failed to properly store medications requiring refrigeration for 2 (R3 and R7) residents. The facility also failed to ensure that medication cart was locked when not in use. These failures can potentially affect 23 residents assigned to V6 (Agency Licensed Practical Nurse) reviewed for medication storage and labeling in 2 of 4 medication storage rooms and 3 of 6 medication carts.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure PPE (Personal Protective Equipment) was properly worn by staff when entering a resident's room on Transmission-Based Precautions with COVID-19 (Coronavirus). This failure has the potential to affect 18 residents residing on the 1B unit. The facility also failed to clean or disinfect reusable equipment, vital sign monitor with stand and was used in between resident during medication administration. This failure can potentially affect 13 residents assigned to V10 (Agency Registered Nurse). Findings Include: 1.) R2 has a diagnosis not limited to Pneumonia, Acute Respiratory Failure with Hypoxia, Venous Insufficiency, Cough, Heart Failure, Essential (Primary) Hypertension and COVID-19. R2's Physician Orders document in part: Maintain Special Droplet Precautions Per Protocol. R2's Care Plan document in part: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the call light was within reach for R14 and failed to respond to R34's needs for two out of a total sample of 25 residents reviewed for call lights.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents' code statuses were consistent with their Physician Orders for Life-Sustaining Treatment (POLST) forms for three (R34, R46, R91) out of a total sample of 25 residents reviewed for Advanced Directives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan for 1 (R72) resident reviewed for wound preventive measures in a sample of 25. Findings Include: R72 has diagnosis not limited to Progressive Supranuclear Ophthalmoplegia, Vitamin D Deficiency, Weakness, Abnormalities of Gait and Mobility, Contracture, Right Hand, Contracture, Left Hand, Muscle Weakness (Generalized) and Lack of coordination. Physician Orders: document in part: pressure relieving mattress to bed and cushion to wheelchair. Care Plan document in part: R72 is at risk for impaired skin integrity due to reduced mobility and incontinence. Impaired mobility due to weakness secondary to progressive supranuclear ophthalmoplegia. Braden Risk Assessment Report dated 07/18/23 document in part: Risk score 15, Risk Level Mild. Mobility: Very limited. Moisture: Occasionally Moist. Activity: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the physician order for wound preventive measures were followed for 1 (R72) resident review for wound prevention in a sample of 25. Findings Include: R72 has diagnosis not limited to Progressive Supranuclear Ophthalmoplegia, Vitamin D Deficiency, Weakness, Abnormalities of Gait and Mobility, Contracture, Right Hand, Contracture, Left Hand, Muscle Weakness (Generalized) and Lack of coordination. Physician Orders: document in part: pressure relieving mattress to bed and cushion to wheelchair. Care Plan document in part: R72 is at risk for impaired skin integrity due to reduced mobility and incontinence. Impaired mobility due to weakness secondary to progressive supranuclear ophthalmoplegia. Braden Risk Assessment Report dated 07/18/23 document in part: Risk score 15, Risk Level Mild. Mobility: Very limited. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident received the correct oxygen flow rate as ordered by the physician and to properly label oxygen tubing and humidifier bottle for 2 (R12, R94) out of 3 residents reviewed for oxygen use in a sample of 25. Findings Include: 1.) On 9/5/23 at 10:44 AM, R12 was lying in bed alert and awake. R12 was receiving supplemental oxygen via nasal cannula at 3 liters per minutes (LPM). R12's oxygen tubing and humidifier bottle had no labels with the dates when they were last changed. On 9/5/23 at 10:57 AM, V8 (Registered Nurse) stated that oxygen tubing is changed on 11-7 shift every Sunday and the humidifier is changed when it's consumed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate was less than 5% for 2 (R67 and R229) of 6 residents reviewed for medication administration. There were 30 opportunities and 5 errors resulting in a 16.67% medication error rate.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that resident is free of any significant medication errors. This failure applies to 1 (R67) of 6 residents reviewed for medication administration in a sample of 25.